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RIGHT-OF-WAY OR CITY EASEMENT <br />SMALL WIRELESS FACILITY <br />APPLICATION <br />CITY OF LAKE ELMO <br />3880 Laverne Avenue North <br />Lake Elmo, Minnesota 55042 <br />Phone: 651.747.3900 <br />Name and Address of Permit Applicant: Name and Address of Party Performing Work: <br />Contact: <br />Phone: <br />24-Hour Emergency Phone: <br />Email address: <br />Contact: <br />Phone:____________________________________ <br />24-Hour Emergency Phone: <br />Email address: <br />1.Nature of Work (indicate on which support structure the small wireless facility is proposed to be located): <br />2.Location (House No., Street, and Nearest Intersection): <br />(Attach 5 copies of scaled drawings showing accurate right-of-way information and planned installation.) <br />3.Method of Construction or Installation: <br />4.Type of Wireless Support Structure:________________________________________________________ <br />5.Height of Wireless Support Structure (not to exceed 50 ft. without City’s authorization):______________ <br />6.Wireless Facility Height (not to extend more than 10 ft. above wireless support structure):____________ <br />7.Work to start on or after and to be completed on or before <br />8.Will detouring of traffic be necessary?  Yes No If so, describe routing: <br />9.A Small Wireless Facility Agreement will also be required. <br />For <br />(Applicant) <br />Signed By <br />Dated <br />The date when the work is completed must be reported to the City of Lake Elmo. <br />Small Wireless Facility Permit Application in the City Right-of-Way or City Easement April 2018 <br />PERMIT NO.