PW_Network_Node_Permit_Application08/31/2017 DH
FOR DEPARTMENT USE ONLY
Permit Number: __________________________________ Permit Fee: ____________________________ Monthly/Annual Fee: ________________________
APPLICATION ACCEPTED BY DATE
CITY AUTHORIZATION BY DATE
CITY OF SCHERTZ
PUBLIC WORKS
10 COMMERCIAL PLACE, BLDG. #2
SCHERTZ, TEXAS 78154
(210) 619-1800, FAX (210) 619-1849
PUBLIC WORKS
Wireless Network Node Permit Application
BUSINESS NAME (APPLICANT):
DATE:
CONTACT PERSON FOR THIS APPLICATION AND INSTALLATION: CONTACT PHONE:
BUSINESS ADDRESS: BUSINESS PHONE: BUSINESS EMAIL:
LOCATION WHERE EQUIPMENT IS TO BE INSTALLED:
NAME OF POLE OWNER: POLE OWNER CONTACT PHONE:
PERMIT REQUIRES:
Certification that equipment being installed complies with applicable regulations of the Federal Communications Committee (FCC).
Certification that the proposed Network Node(s) will be placed into active commercial service by or for the network provider no later than
the 60th day after the date of construction and final testing is completed.
Detailed engineered drawings and construction documents for all equipment to be installed within the right of way, including calculations
demonstrating strict conformity to size limitations (Chapter 284 of the Texas Local Government Code) and certification that all installations
comply with all Applicable Codes.
Declaration complying with the City of Schertz Design Manual regarding prohibited areas, such as City parks and residential areas and any
location within 300 feet of a historic site, structure of landmark.
Proposed concealment measures must be included with permit application, if node or node support pole is in a design or historic district.
Proposal for pole camouflage must be included with permit application.
CHECK ALL APPROPRIATE BOXES FOR TYPE OF INSTALLATION(S):
WIRELESS NETWORK NODE: # of UNITS _________ WIRELESS WIRELESS TRANSPORT FACILITY
COLOCATION OF EQUIPMENT ON CITY POLE: # OF POLES_________
COLOCATION OF EQUIPMENT ON NON-CITY OWNED POLES: # OF POLES ________
NETWORK NODE POLE TO BE INSTALLED: # OF UNITS __________
TRANSPORT FACILITY(IES): # of UNITS __________
_______________________________________________________________________________________________________________________
CHECK ALL APPROPRIATE BOXES FOR ADDITIONAL INFORMATION ON INSTALLATION(S):
DISCLOSURE IF INSTALLATION IS WITHIN 300 FEET OF A HISTORIC SITE, STRUCTURE, OR LANDMARK.
INDUSTRY STANDARD POLE LOAD ANALYSIS.
DISCLOSURE OF INSTALLATION WITHIN AN AREA THAT HAS UNDERGROUNDING REQUIREMENTS.
CERTIFIED ANALYSIS THAT THE NETWORK NODE WILL CAUSE NO INTERFERENCE WITH ANY CITY COMMUNICATIONS.
PERMIT FROM STATE OR FEDERAL GOVERNMENT TO INSTALL PROPOSED EQUIPMENT WITHIN THE STATE OR FEDERAL
HIGHWAY RIGHT OF WAY IF APPLICABLE.
DISCLOSURE IF LOCATED IN/ON ANY OF THE FOLLOWING: DECORATIVE POLES, IN AN AREA OF THE CITY WITH
UNDERGROUNDING REQUIREMENTS, OR AN AREA ADJACENT TO A STREET OR THOROUGHFARE THAT IS NOT MORE THAN
50 FT WIDE, ADJACENT TO SINGLE-FAMILY RESIDENTIAL LOTS OR OTHER MULTI-FAMILY RESIDENCES, OR UNDEVELOPED
LAND THAT IS DESIGNATED FOR RESIDENTIAL USE BY ZONING OR DEED RESTRICTIONS. (IF YES TO ANY OF THE ABOVE,
PLEASE PROVIDE MAPS IDENTIFYING LOCATION AND DESIGN OF INSTALLATIONS.)
FILL IN ALL INFORMATION THAT CORRESPONDS WITH INSTALLATION(S) ABOVE:
GIS COORDINATES:_________________________________________________ POLE TYPE: _______________________________________
ZONING DISTRICT: __________________________________________________ HISTORIC DISTRICT:________________________________
NUMBER OF ANTENNAS: ____________________________________________ HEIGHT OF ATTACHMENT: __________________________
BACKHAUL SOLUTION: ______________________________________________ OPERATING FREQUENCIES: _________________________
INSURANCE REQUIREMENTS: The Franchisee agrees to carry general liability insurance naming the City as additional insured in the minimum amount of $1,000,000 for each occurrence and $2,000,000 annual aggregate; automobile liability naming the City as additional insured in the amount of $1,000,000 combined single limit, and worker compensation/employer liability insurance. Such policy or policies shall provide by endorsement that it may only be cancelled or amended by the insurance company only
after (30) day’s prior written notice to the City Manager. Certificate of Insurance issued by the insurer evidencing the coverage, cancellation, and amendment provisions set
forth in this section, must be submitted to the City with the Permit Application, and a certificate or certificates issued by the insurer confirming the continuing effectives of
such coverage, cancellation, and amendment provisions shall be submitted to the City prior to any construction commencing. Upon written request by the Public Works
Director of his designee either the original policy (or policies) or copies certified by the insurer must be delivered to the City
____________________________________________________________________________________________________________________________________
SIGNATURE (Owner, Contractor, Authorized Agent) DATE
____________________________________________________________________________________________________________________________________
PRINT NAME (Owner, Contractor, Authorized Agent) DATE