SMALL WIRELESS FACILITIES PERMIT APPLICATION |
APPLICANT INFORMATION |
Applicant Name: __________________________________ Date: _______________________ |
Applicant is a: __ Carrier/Wireless Provider __ Representative __ Other |
Company Name: ________________________________________________________________ |
Address: _______________________________________________________________________ |
City: ____________ State: ____________________ ZIP Code: _______________________ |
Phone: ______________________ Email: ________________________________________ |
PROPOSED SITE LOCATION |
Property Address: _______________________________________________________________ |
City: _________________________ State: _______________ ZIP Code: _______________ |
Closest Intersection (Distance and Direction from): |
_______________________________________________________________________________ |
_______________________________________________________________________________ |
EXISTING POLE/STRUCTURE INFORMATION |
New Pole/Structure Construction? __ Yes __ No |
Pole/Structure ID Number: _______ Height of Pole/Structure (feet): ______ Pole Color: _____ |
Existing Attachment(s) on Pole/Structure? (e.g. banners, light fixtures) ___ Yes ___ No |
Existing Structure Owner: ________________________________________________________ |
Name of Structure Owner Representative: ___________________________________________ |
Address: ______________________________________________________________________ |
City: __________ State: ____________ ZIP Code: __________ |
Phone: __________ Email: _________________ Fax: ______________________ |
PROPERTY OWNER INFORMATION |
In the event that the proposed small wireless facility is to be attached to an existing pole owned by an entity other than the Village, the wireless provider shall provide legally competent evidence of the consent of the owner of such pole to the proposed collocation. Permission has been granted by property owner? ___ Yes ___ No |
Name: ________________________________________________________________________ |
Address: ______________________________________________________________________ |
City: ____________ State: ________________ ZIP Code: _______________ |
Phone: ____________________ Email: ______________________ |
APPLICATION REQUIREMENTS |
The following documents must be attached or included for the Application to be complete: |
__ Application fee(s) |
__ Site specific structural integrity, AND for a municipal utility pole |
__ Make-ready analysis prepared by a structural engineer |
__ The location where each proposed small wireless facility or utility pole would be installed |
__ Photographs of the proposed site location and its immediate surroundings |
__ Specifications and drawings prepared by a structural engineer for each proposed small wireless facility |
__ The equipment type and model numbers for the antennas and all other wireless equipment associated with the small wireless facility |
__ A proposed schedule for the installation and completion of each small wireless facility, if approved |
__ Proof of permission granted by property owner, if existing pole not owned by the Village |
ATTESTATION, ACKNOWLEDGMENT & SIGNATURE |
I attest to the best of my knowledge and belief, that the information stated in this application and in all supporting plans and documents is true and accurate. To the best of my knowledge, I certify that the proposed collocation complies with the terms of the “Collocation Requirements and Conditions” section of the Village of Flanagan’s Small Wireless Facility Deployment Ordinance No. 18-____ |
Signature of Applicant: ______________________________ Date: _______________________ |
Printed Name of Applicant: ____________________________ Title: ____________________ |
**FOR ADMINISTRATIVE USE ONLY** |
Date Application was submitted: ______________________________ |
Application is: ___ Complete ___ Incomplete |
If incomplete, date the Applicant was notified: _____________________________ |
Missing documents or information: _________________________________________________________________________________ _________________________________________________________________________________ ____ |
(Document, “Small Wireless Facilities Permit Application”)