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2. 1. Installation Types
4. Small-Cell Facilities (check at least one)

   1. New Installation / Collocation
   2. Replacement / Modification
   3. Removal
5. Wireless Support Structures (check at least one)

   1. New Installation / Collocation
   2. Replacement / Modification
   3. Removal
7. Quantity of Small-Cell Facilities
8. Quantity of Wireless Support Structures
10. If Collocation, name of the existing Wireless Support Structure Owner:
12. 2. Applicant Information
14. (a) Operator / Utility Provider:
16. Company Name*
18. Address*
20. City*
21. State*
22. Zip Code*
24. Contact Person:
26. First Name*
27. Last Name*
29. Phone Number*
30. Cell Phone Number*
32. Email Address*
34. (b) Permit Agent, if different than Operator
36. Company Name
38. Address
40. City
41. State
42. Zip Code
44. Contact Person:
46. First Name
47. Last Name
49. Phone Number
50. Cell Phone Number
52. Email Address
54. Is Applicant the Operator of the Proposed Small-Cell Facility and / or Wireless Support Structure?*

    1. Yes
    2. No - If “No” Is Applicant serving as an agent for the Operator?
    3. Yes, applicant is serving as agent for the Operator
    4. No, applicant is NOT serving as agent for the Operator
56. 3. Installation Location(s)
58. (a) Small-Cell Facilities Site Coordinates (Latitude / Longitude)*
59. (b) Small-Cell Facilities Site Coordinates (Latitude / Longitude)*
61. 4. Preliminary Construction Schedule
63. (a) Upon approval, construction start date:*
    (a) Upon approval, construction start date:
64. (b) Completion Date*
    (b) Completion Date
66. 5. State and Federal Laws*

    Does the Applicant certify that the proposed Small-Cell Facility and/or new Wireless Support Structure fully comply with all state and federal regulations

    1. Yes
    2. No
68. 6. Submittals

    1. Please complete this application to apply for an Encroachment Permit for Small-Cell Facilities in the public right-of-way. Please reference Small-Cell Facilities Requirement for more details on the process in the City Manager’s Office, Small-Cell Facilities Information, www.cityofholland.com/citymanager. 

    (a) New Installation / Collocation / Modification / and Replacement

    Applicant must submit the following documents:

    • A certificate of compliance with FCC rules related to radio frequency emission from a small cell wireless facility is required.
    • An attestation that the construction of the proposed small-cell facility will commence within one (1) year of final approval and be diligently pursued to completion, unless the City and the Applicant agree to extend the period.
    • Applicant may file a consolidated application and receive a single permit for the co-location of up to 20 small cell wireless facilities.
    • Applicant must submit a processing fee of $_________ for each Small-Cell Facility included in this Application.  Make check payable to the City of Holland.
    • Aerial map and street view image map(s) for any proposed small cell wireless facilities which shall be legible, to scale, labeled with streets, and contain sufficient detail to precisely identify the proposed small cell wireless facilities' locations and surroundings is required.
    • Photo simulation of any installations, including proposed paint color.
    • Equipment specifications.
    • Electrical service drawings.
    • Landscape plan for ground-mounted equipment, if applicable.
    • Evidence of owner’s authorization to collocate on the existing structure, if applicable.
    • All proposed locations for small-cell wireless facility shall field-stake.
    • The permittee shall be responsible to obtain such other pole attachment agreements, permits and approvals as otherwise required by law.
    • Applicant shall submit an RF Study justifying the need for small-cell facility.

    (b) Removal

    Applicant must submit the following:

    • Aerial map and street view image.
    • Description of the steps for removal and restoration of the right-of-way.

    To the best of my knowledge, the information contained within this application is true,

70. Certificate of Compliance*
71. Photo Simulation*
72. Proposed Locations*
74. Attestation*
75. Equipment Specifications*
76. RF Study*
78. Aerial Map*
79. Electrical Service Drawings*
80. Description of Steps for Removal
82. Street View Image Map(s)*
83. Landscape Drawing Plan*
85. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
87. Electronic Signature*
88. Date*
    Date
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit

* indicates a required field