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2. PERMITTEE INFORMATION
4. Applicant Name*
5. Company/Organization*
7. Contact Person*
8. Contact Phone Number
9. Contact Email Address*
11. Mailing Address*
13. Is the Applicant a FCC‐Licensed Provider of Wireless Services?*

    1. Yes
    2. No
14. Applying for New Use Permit*

    1. Yes
    2. No
15. Applying for Permit Renwal?*

    1. Yes
    2. No
17. If No, provide documentation authorizing this work to be performed in the right-of-way*
18. If Yes, Provide the Permit Number for Renewing*
20. CONTRACTOR INFORMATION
22. Company Contracted for the Project*
23. Company Phone Number*
24. Company Email Address*
26. Mailing Address*
28. Project Supervisor Name*
29. 24-Hr Phone Number*
30. Email Address*
34. PROPOSED INSTALLATION AND LOCATION DETAILS

    UP TO 25 STRUCTURES PER PERMIT

36. Wireless Support Structure Type*
    -- Select One --Existing Utility Pole(s)Non-Ornamental Municipal Service Pole(s)New Pole(s)Ornamental Municipal Service Pole(s)Other
38. Specify*
40. Number of Structure(s)*
41. Is Collocation Possible?*

    1. Yes
    2. No
42. If No, provide justificaiton if not feasible*
44. Owner of Structure(s)*
46. Select Installation Area Classification*
    -- Select One --IndustrialHighway ROWRetail/CommercialResidential
48. TECHNICAL SPECIFICATIONS
50. Description of Equipment*
52. Description of Power Source*
54. Will Ground Equipment be Necessary?*

    1. Yes
    2. No
55. If Yes, provide location and concealment details*
57. DESIGN AND AESTHETIC INFORMATION
59. Describe Camouflage/Concealment Plan*
61. Are there any Logos or Lighting Involved?*

    1. Yes
    2. No
63. If Yes, detail compliance with standard requirements*
65. COMPLIANCE AND SAFETY CONFIRMATION
67. Load Analysis Approval
69. Describe Noise Suppression Plan*
71. Describe Tree Maintenance Plan
75. ATTACHMENTS
77. Map, Site Plans, and Diagrammatic Representations*
79. Manufacturer Specifications*
81. Written Permission from Owner of Pole/Structure(s) for Use with Contact Information*
83. A Surety Bond of $5,000 from a company authorized in Iowa*
85. Certificate of General Liability Insurance covering the City of West Burlington against claims, injuries or damages to person(s) or property caused by the proposed work, in amount of $1,000,000*
89. COMPLIANCE ACKNOWLEDGEMENT
91.  *

    1. I certify that the information provided in this application, and in all supporting plans and documents, is true and accurate to the best of my knowledge and I acknowledge that I have a continuing obligation to inform the City if there is a change in the information contained in this application.
93.  *

    1. I acknowledge that the collocation of small cell wireless facilities shall commence within 6 months of permit issuance and shall be activated for use no later than 1 year from the permit issuance date.
95.  *

    1. I certify that I have read the City of West Burlington, Iowa Small Cell Guidelines
96.  Link to Guidelines
    click here
98.  *

    1. I acknowledge compliance with all applicable state and federal laws, as well as city guidelines.
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100. Submit

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