HomeMy WebLinkAbout8-Small Wireless Facility Permit ApplicationRIGHT-OF-WAY OR CITY EASEMENT
SMALL WIRELESS FACILITY
APPLICATION
CITY OF LAKE ELMO
3880 Laverne Avenue North
Lake Elmo, Minnesota 55042
Phone: 651.747.3900
Name and Address of Permit Applicant: Name and Address of Party Performing Work:
Contact:
Phone:
24-Hour Emergency Phone:
Email address:
Contact:
Phone:____________________________________
24-Hour Emergency Phone:
Email address:
1.Nature of Work (indicate on which support structure the small wireless facility is proposed to be located):
2.Location (House No., Street, and Nearest Intersection):
(Attach 5 copies of scaled drawings showing accurate right-of-way information and planned installation.)
3.Method of Construction or Installation:
4.Type of Wireless Support Structure:________________________________________________________
5.Height of Wireless Support Structure (not to exceed 50 ft. without City’s authorization):______________
6.Wireless Facility Height (not to extend more than 10 ft. above wireless support structure):____________
7.Work to start on or after and to be completed on or before
8.Will detouring of traffic be necessary? Yes No If so, describe routing:
9.A Small Wireless Facility Agreement will also be required.
For
(Applicant)
Signed By
Dated
The date when the work is completed must be reported to the City of Lake Elmo.
Small Wireless Facility Permit Application in the City Right-of-Way or City Easement April 2018
PERMIT NO.