Fillable City Of Oakland Cannabis Permit Application 010219

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City Of Oakland Cannabis Permit Application 010219

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CannabisPermitApplication1

CANNABISPERMITAPPLICATIO

N

1a.AddressofProposedCannabisOperation:

__________________________________________________________________________________

1b.Areyouwithin300’ofaresidentialzone?

YesNo

Notyetsecuredalocation



Applicantswhohavenotyetsecuredalocationmaysubmitanapplicationandbeconditionallyapproved,however,inorderto

obtainapermit,Applicantswilleventuallyhavetoidentifytheirbusinesslocationsothatitcanbereviewedandinspected.

1c.Didwork/liveorresidentialuseexistonMarch6,2018intheportionofthepropertywhere

applicantproposestoconductcommercialcannabisactivity?*

YesNo

*OnMarch20,2018theOaklandCityCouncilamendedtheCity’scannabisordinances,OMC5.80and5.81,to

prohibittheissuanceofacannabispermitorlocalauthorizationtoacannabisapplicantatpremiseswhereeither

work/liveorresidentialuseexistedasofMarch6,2018.



2. RighttoOccupyProposedCannabisLocation:

OwnerTenant IntendtoLease/PurchaseNotyetsecuredalocation

Pleaseprovideacopyofthesupportingdocuments:

Deed LeaseAgreement Letterofintenttolease/purchaseproperty

Ifapplicantisnottheowner,pleasepro

videthefollowinginformationforthepropertyowner:

LastName: FirstName: MiddleInitial:

Phone: Email:

ResidentialAddress:

City: State: Zip:

OnOctober2,2018,theCityCouncilpassedamendmentstotheCity’scannabispermitordinance.These

amendmentsincludeapublicnoticeandcommunitymeetingrequirementforallapplicationssubmittedafter

October2

thatidentifyanaddressthatiswithin300feetofaresidentialzone.Theintentbehindthe

requirementistoprovideanopportunityforoperatorstopresenttheirproposedusetonearbyresidentsandhear

whatconcernsorsuggestionsneighborshaveregardingthebusinessatacommunitymeeting.



CannabisPermitApplication2



3.ApplicantInformation:



a. Name:_______________________________________________________________________



b.TypeofCorporateStructure:



CorporationLimitedLiabilityCompanyPartnershipIndividual



CollectiveOther:_________________________________________________





c. DoingBusinessAs:____________________________________________________________________



d. PleaseAttachaCopyofStateregistration



e. Partner/Owner/ManagerInformation:

Pleaselistallpersonsdirectlyorindirectlyinterestedinthepermitsought,includingallofficers,directors,general

partners,managingmembers,stockholders,andpartners.Pleaseattachadditionalpagesifnecessary(additional

pagesshouldbeon8½x11”paper;singlesided,andincludeaHeaderwiththeapplicant’snameonthetop

right

cornerofeachpage).



LastName: FirstName: MiddleInitial:

Alias(es):

Title:

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



LastName: FirstName: MiddleInitial:

Alias(es):

Title:

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



LastName: FirstName: MiddleInitial:

Alias(es):

Title:

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



CannabisPermitApplication3



LastName: FirstName: MiddleInitial:

Alias(es):

Title

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



LastName: FirstName: MiddleInitial:

Alias(es):

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



LastName: FirstName: MiddleInitial:

Alias(es):

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



LastName: FirstName: MiddleInitial:

Alias(es):

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



4.PermitRevocations

Haveanyofthepersonsdirectlyorindirectlyinterestedinthepermitsought everhadapermit

revoked?

YesNo



Ifyes,pleasedescribebelowthecircumstancesofsuchrevocation.



CannabisPermitApplication4



5. Equity



TheEquityPermitProgramdescribedunderOMC5.80.045andOMC5.81.060definesan

“EquityApplicant”asanApplicantwhoseownership/owner

:

1.IsanOaklandresident;and 

2. Has an annual income at or less than 80 percent of Oakland Average Medium Income (AMI)

adjustedforhouseholdsize(clickherefor80percentOaklandAMIthresholds);and

3.Either

(i)haslivedinanycombinationofOaklandpolicebeats2X,2Y,6X,7X,19X,21X,21Y,23X,26Y,

27X,27Y, 29X, 30X,30Y, 31Y,32X, 33X,34X, 5X, 8Xand35Xfor atleast ten ofthe lasttwenty

yearsOR

(ii) was arrested after November 5, 1996

 and convicted of a cannabis crime committed in

Oakland.

Yes,Ifulfilltheequity criteriaNo,Idonotfulfilltheequitycriteria





Ifyes,pleaseprovidesupportingdocumentationasdescribedbelow.



For proof of ownership please provide entity formation documents or documents filed with the

California Secretary of State (e.g. articles of incorporation, stock issuance records, operating

agreements,partnershipagreements).

Forproofofincomepleaseprovidefederaltaxreturnsandatleastoneofthefollowingdocuments:two

monthsofpaystubs,currentProfitandLossStatement,BalanceSheetorproofofcurrenteligibilityfor

General Assistance, Food Stamps,  Medical/CALWORKs or Supplemental Security Income or Social

SecurityDisability(SSI/SSDI).





“Ownership”shallmeantheindividualorindividualswho:

i. Withrespecttofor‐profitentities,includingwithoutlimitationcorporationspartnerships,limited

liabilitycompanies,hasorhaveanaggregateownershipinterest(otherthanasecurityinterest,

lien,orencumbrance)of50%ormoreoftheentity.

ii. Withrespecttonot

for‐profitentities,includingwithoutlimitationanon‐profitcorporationor

similarentity,constitutesorconstituteamajorityoftheboardofdirectors.

iii. Withrespecttocollectivehasorhaveacontrollinginterestinthecollective’sgoverningbody.

ApplicantswhodonotsatisfytheEquitycriteriawillbereviewedasGeneralApplicantsandtheirapplicationswill

beprocessedsubjecttotherestrictionsofOMC5.80.045and5.80.060.



CannabisPermitApplication5

For proof of residency a mini

mum of two of the documents listed below, evidencing 10 years of

residency shall be considered acceptable proof of residency.All residency documents must list the

applicant’s first and last name, and the Oakland residence address in applicable police beats.

Documents provided in 2019 will not be considered for proof a year of residency, it can be used for

proofofcurrentresidencyonly.

 Californiadriver'srecord;or

 Californiaidentifica

tioncardrecord;or

 Propertytaxbillingandpa yments;or

 VerifiedcopiesofstateorfederalincometaxreturnswhereanOakland addressislisted

asaprimaryaddress;or

 Schoolrecords;or

 Medicalrecords;or

 Bankingrecords;or

 OaklandHousingAuthorityrecords;or

 Utili

ty, cable or internet company billing and payment covering any month in each of

thetenyears.

Proof of Conviction should be demonstrated through Court documents, Probation documents,

DepartmentofCorrectionsorFederalBureauofPrisonsdocumentation.

6. EquityIncubator

Generalapplicantsthatserveasincubatorsforequityapplicantsbyprovidingfreerentorrealestateare

entitledtopermittingpriority.

Inordertoreceivethispermittingpriority,theGeneralApplicantmustcomplywiththefollowing

conditions:

a. Thefreere

alestateorrentshallbeforaminimumofthreeyears.

b. The Equity Applicant shall have access to a minimum of 1,000 square feet to conduct its

businessoperations.

c. The General Applicant mustprovideany City required securitymeasures, including camera

systems,safes,andalarmsystemsforthespaceuti

lizedbytheEquityApplicant.

d. TheGeneral Applicant is otherwisecompliant with allother requirements of OMC Chapter

5.80or5.81.

Yes,Iwillbeincubatingthefollowingequityapplicant:

Howdidyoumeetyourin

cubator/incubatee?_______________________________________________

CannabisPermitApplication6

Ifyes,pleasesubmitsuppo

rtingdocuments,includingacopyoftheleaseand/orcontractual

agreementsbetweenGeneralandEquityApplicants.

IaminterestedinbeingpartoftheEquityIncubatorProgrambuthavenotyetconnectedwitha

matchingEquity/GeneralApplicant.



Iamageneralapplicantandnotinterestedinincubating.

IamanequityapplicantandIamnotinterestedinbeingincubated

IamanequityapplicantandIambeingincubatedby:___________________________________

7. TypeofLicense:Medical AdultUse Medi

calandAdultUse

DeliveryOnly‐Dispensary IndoorCultivatorOutdoorCultivator

Distributor Transporter TestingLaboratory

Manufacturing withvolatilesolvents Manufacturingwithnon‐volatilesolvents

Extraction Extraction

Infusion Infusion

Packaging Packaging

8. Pr

ojectedAnnualGrossReceipts:

Cannabissales<$500,000

Cannabissalesbetween<$500,001‐$999,999

Cannabissales>$999,999

9. Security

a. Pleasesubmi

tafloorplan,drawntoscaleon81/2x11”paperthatincludes:

i. layoutoftheestablishment,includingparkinglots;

ii. principalusesofeachsection;

iii. limitedaccessareas;

iv. safes;

v. alarms;

vi. securitycameras.

b. Describe(innomorethantwopages)whatmeasu

resApplicantwilltake

i. topreventaburglaryorarmedrobbery;and

ii. tominimizethelossofproductinthecaseofaburglaryorarmedrobbery.

c. Ifutilizingaprivatesecurityservice,pleaseprovide

i. Companyname;and

Applicantsinterestedinmeetingpotentialpartnerscanvisitwww.cannaequity.org

CannabisPermitApplication7

ii. Statelice

nsenumber.

d. PleaseconfirmApplicantwillutilizerealtimeIPcameras

byprovidingthename(s)andcontact

infofortherepresentative(s)available24hoursonbehalfofApplicanttoprovidetheOakland

PoliceDepartmentwithaccesstothiscamerafootageincaseofanemergency:

Name(s):

____________________________________________________________________________

Phone(s):

____________________________________________________________________________

Email(s):

_____________________________________________________________________________

10. OdorMitigation

Pleasesubmitaplan(innomorethantwopages)forhowca

nnabisodorswillnotbedetectableoutside

oftheproposedfacility,suchasutilizationofcarbonfilters.

11. CommunityBeautificatio nPlan

Pleasesubmitacommunitybeautificationplan(nomorethantwopages)detailingspecificstepsyour

businesswilltaketoreduceillegaldumping,littering, graffiti andblightandpromotebea

utificationof

theadjacentcommunity.

12. MinimizingEnvironmentalImpact(onlyIndoorCultivatorsmustcomplete)

Priortopermitissuance,theCityofOaklandwillrequirethatcultivatorsdemonstrate

that100%oftheir

electricityisderivedfromrenewableorcarbonfreesources.ThiscanbedonebyenrollinginEastBay

CommunityEnergy’sBrilliant100program(https://ebce.org/power‐mix/)andforwardingemailconfirmation

ofenrollmenttocannabisapp@oaklandca.gov

13. Ve

hicleInsurance(onlyDelivery‐OnlyDispensariesandTransportersmustcomplete)

PleaseprovidetheinformationrequestedbelowonallvehiclesinvolvedinApplicant’soperationand

provideproofofinsurance.

Proofofinsurancemayincludequotationsfromaninsuranceagency,aletterofintent/”willserve”

letter

,and/orcertificatesofinsurance.Pleasenote,anyquotationorletterofintentmustbeon

officialagencyletterheadand/ordocumentsandaletterofintentmustbesignedbyaqualifiedagentof

aninsurancecompany.Pleaseattachadditionalpagesifnecessary.

CamerasthatcansendandreceivedataviaacomputernetworkandtheInternet.

Pleasenote,thewhileaquotationorletterofintentissufficientatthetimeofapplication,theinsurancepolicy

mustultimatelybeinplacepriortotheissuanceoftheactualcannabispermit.

CannabisPermitApplication8

Insurancemu

stminimallyinclude:

 CommercialGeneralLiabilitywithalimitof$1,000,000peroccurrence/aggregate

 Commercial/BusinessAutoLiabilitywithacombinedsinglelimitof$1,000,000

 HiredandNon‐OwnedAutoLiabilitycoverage

 Worker’sCompensationCoverage

REGISTEREDOWNER:

VEHICLEMAKE: VEHICLEMODEL:

LICENSENUMBER: REGISTRATIONEXPIRATION:

VIN:

INSURANCECARRIER&POLICYNUMBER:

REGISTEREDOWNER:

VEHICLEMAKE: VEHICLEMODEL:

LICENSENUMBER: REGISTRATIONEXPIRATION:

VIN:

INSURANCECARRIER&POLICYNUMBER:

14. SupportingDocuments.

Pleaseche

cktheboxesbelowforeachsupportingdocumentsubmittedwiththisapplication.

Pleaseensurethat

allsupportingdocumentsincludeaHeaderwiththeapplicant’snameonthetoprightcornerofeachpage.

Proofofpropertyownership/leaseagreementorletterofintenttorent/lease/purchase

CopyofStateRegistrationforcorporatestructure

Floorplan

Securityplan

OdorMitigationPlan

CommunityBeautificationPlan

ForEquityApplicantsOnly:

ProofofOwnership

ProofofIncome

Andeither

ProofofRes

idencyorProofofConviction

ForEquityIncubatorApplicantsOnly:

Leaseorothercontractprovidingfreerealestateorrentforaminimumofthreeyearsindicatingsquarefootage

availabletotheEquityApplicant

 Proofofproviding requiredsecuritymeasures,includingcamerasystems,safes,andalarmsystemsforthe

spaceutilizedbytheEquityApplicant.

ForIndoorCultivatorsonly:

ConfirmationofenrollmentinEastBayCommunityEnergy’sBrilliant100program

CannabisPermitApplication9

ForDelive

ry‐OnlyDispensariesandTransporters

ProofofVehicleInsuranceorLetterofintent/”will”serveletter

14. OathofApplication

I,theun

dersigned,declareunderpenaltyofperjurythattothebestofmyknowledge,theinformation

containedinthisapplicationanditssupportingdocumentationistruthful,correctandcomplete;and,

theinformationcontainedinthisapplicationanditssupportingdocumentationdisclosesallfacts

regardingtheapplicant andassociatedi

ndividualsnecessarytoallowtheCityAdministratortoproperly

evaluatetheapplicant’squalificationsforregistration. 

I,theundersignedfurtheragreeandacknowledgethatImayberequiredtoprovideadditional

informationasneeded,foracompleteinvestigationbytheCityAdministrator.

I,theundersigned,furtheragreeandrecognizethatIamresponsibleforobeyingallFederal

,State,

Countyandlocallaws.

I,theundersigned,furtheragreeandunderstandthatanymisrepresentations,omissionsorfalsifications

intheapplicationoranydocumentsattachedtheretooramendmentstheretowillbeimmediate

groundsfortheCityAdministratortodenythispermitapplicationand/orimme

diategroundsfor

revocationofacannabispermit.

APPLICANTNAME:

SIGNATURE:

DATE:

SPECIAL ACTIVITY PERMITS • 1 Frank H. Ogawa Plaza, 1st Floor • Oakland, CA 94612

PRELIMINARY CHECKLIST FOR CANNABIS OPERATORS PURSUANT TO THE

CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA)

APPLICANT NAME: _________________________________________________________

DBA: _____________________________________________________________________

APPLICANT CONTACT INFORMATION:

Phone No.: _______________________________________________________

E-mail: __________________________________________________________

Property Owner: _________________________________________________________________

Property Owner Mailing Address: ___________________________________________________

City/State:_____________________________________Zip: ______________________________

Phone No.: ______________________ E-mail: _______________________________________

I authorize the applicant indicated above to submit the application on my behalf.

Signature of Property Owner: _____________________________________________________

I. SITE INFORMATION

Project Address: __________________________________________________________

Project APN: ____________________________________________________________

CITY OF OAKLAND

Office of the City Administrator

PROPERTY OWNER AND APPLICANT INFORMATION

(Only complete if different from Applicant)

Original signatures or clear & legible copies are required.

Project Overview and Description:

What is the approximate square footage for each cannabis activity at your proposed site?

Delivery __________________________ Distribution _______________________

Indoor Cultivation ___________________ Outdoor Cultivation __________________

Volatile Manufacturing _______________ Non-Volatile Manufacturing ___________

Transporter _________________________ Lab Testing ________________________

What is the approximate square footage of the lot on which the cannabis activity will take place?

_________________________________________________

Is the project new construction or rehabilitation of an existing facility?

 New Construction  Rehabilitation of an existing facility

If rehabilitation, is the number of units or square footage being changed? Yes  No (Explain if yes)

What was the prior use of the property/premises?

If your application is approved, will there be multiple cannabis operators located at the property?

 Yes  No

If yes, how many and what is the approximate total square-footage for all cannabis operators?

Have you incorporated any measures into your project to mitigate or reduce potential environmental

impacts?  Yes  No  Unknown

If so, list them here. (Examples include enrollment in clean energy programs, tree preservation plans,

creek restoration plans, and open space easements.)

Will the Project utilize a carbon dioxide generator as part of your cannabis facility?  Yes  No

If yes, will the carbon dioxide generator emit carbon dioxide into the air and at what levels? Please

explain and provide consultant report if necessary.

II. HISTORIC RESOURCES

Is the project site located within a historic district, or contain a historic building?  Yes  No

(Historic information can be obtained from the Planning & Zoning Division at (510) 238-6879)

a) What is the OCHS (Oakland Cultural Heritage Survey) rating of the building?

___________________________________________________________________________

b) If so, is the building proposed for demolition or alteration?

___________________________________________________________________________

c) Is there a California Office of Historic Preservation DPR Form 523 with rating of 1 to 5?

__________________________________________________________________________

Note: Any modification to a historic building will require additional CEQA analysis and may not be eligible for a CEQA exemption.

III. HAZARDOUS MATERIALS

Is the subject property located on a State List of sites containing hazardous materials compiled

pursuant to Section 65962.5 of the Government Code?

 Yes  No

(Cortese list, among others; more information can be obtained from California EPA at

https://www.dtsc.ca.gov/SiteCleanup/Cortese_List.cfm)

a) If so, has the site been remediated? ______________________________________________

b) Is there a “Closure Letter” from the appropriate regulatory Agency? ____________________

c) If not remediated, is there an approved Remedial Action Plan (RAP)? ___________________

d) If not, has a RAP been submitted? ______________________________________

IV. OTHER

Is the applicant aware of any other environmental conditions/impacts likely to require further CEQA or

National Environmental Policy Act (NEPA) review, such as:

i. Sensitive environments, e.g., creeks-wetlands, seismically active areas  Yes  No

ii. Peculiar or unique characteristics of the site, the project, or adjacent uses  Yes  No

Please explain:

I understand that review and approval of this preliminary CEQA checklist does not

constitute approval for any administrative review, conditional use permit, variance, or exception

from any other City regulations which are not specifically the subject of this application. I

understand further that I remain responsible for satisfying requirements of any private

restrictions or covenants appurtenant to the property. I understand that the Applicant and/or

Owner phone number listed above will be included on any public notice, if any, for the project.

I certify that I am the applicant and that the information submitted with this preliminary

CEQA checklist is true and accurate to the best of my knowledge and belief. I understand that

the City is not responsible for inaccuracies in information presented, and that inaccuracies may

result in the revocation of any permits as determined by the City. I further certify that I am the

owner or purchaser (or option holder) of the property involved in this application, or the lessee or

agent fully authorized by the owner to make this submission, as indicated by the owner’s signature

above.

I certify that statements, if any, made to me about the time it takes to review and process

this application are general. I am aware that the City has attempted to request everything

necessary for an accurate and complete CEQA review of my proposal; however, that after this

preliminary CEQA checklist and/or application has been submitted and reviewed by the City

Administrator’s Office, it may be necessary for the City to request additional information and/or

materials. I understand that any failure to submit the additional information and/or materials in

a timely manner may render the application inactive and that periods of inactivity do not count

towards statutory time limits applicable to the processing of this application.

Signature of Applicant: __________________________________________________

Date: ______________________________________

I HEREBY

CERTIFY

, UNDER PENALTY OF PERJURY, THAT ALL THE

INFORMATION PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT.

CEQA Review done by: ______________________________________________Date: ___________________________

Findings: Exempt Needs Additional Information

Notice of Exemption completed by: ___________________________________Date: _____________________________

FOR

OFFICE

USE

ONLY

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City Of Oakland Cannabis Permit Application 010219

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Completed 24 July 2020

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