WIRELESS FACILITY PERMIT APPLICATION - City of Santa Monica

Department of Public Works
Phone: (310) 458-8721 Fax: (310) 393-4425
WIRELESS FACILITY PERMIT APPLICATION
(Installations in the Public Right-of-Way)
All sections must be completed.
Incomplete application forms will not be accepted.
Date: ___________________
Permit Number: _______________
Applicant
Company: ___________________________________________________________
Contact Name: _________________________________________________________
Address: ___________________________________________________________
___________________________________________________________
Phone Number: _________________________________________________________
City Business License Number (if applicable): _________________________________
Location
This application is for installation of a wireless telecommunication facility at:
______________________________________________________________________
______________________________________________________________________
Utility Company on Behalf of Whom Application is filed
Company: ___________________________________________________________
Contact Name: _________________________________________________________
Address: ___________________________________________________________
___________________________________________________________
Phone Number: _________________________________________________________
Page 1 of 2
F:\CivilEngineeringandArchitecture\Share\CE LAND DEVELOPMENT\EXCAVATION AND WIRELESS FACILITY PERMITS PROCESS AND
PROCEDURE\Forms\Current\WIRELESS FACILITY PERMIT APPLICATION REV120619.doc

Utility Company on Behalf of Whom Application is filed (continued)
City Business License Number: ____________________________________
What is the Utility’s legal authority to occupy the public right-of-way? _______________
______________________________________________________________________
Contractor Performing Work
Company: ___________________________________________________________
Contact Name: _________________________________________________________
Address: ___________________________________________________________
___________________________________________________________
Phone Number: _________________________________________________________
City Business License Number: ____________________________________________
The following documents are attached hereto:
Construction Plans (3 copies 24” by 36” size)
Includes: Site Plan and Utility Study per SMMC 7.06.060
Construction Schedule
Photos, computer simulations, or other accurately scaled drawing representing the
aboveground facility before and after the installation.
Certified documentation by a licensed engineer demonstrating compliance with
Federal standards for NEIR and EMF fields.
Radius map and certified list of the names of property owners and addresses within
a five hundred (500) foot radius of the proposed installation (major permits only).
Traffic Control Plan
Documentation confirming that the proposed wireless facility meets design
standards per SMMC 7.06.230.
Authorized Representative:
Applicant agrees to abide by all requirements of the Santa Monica Municipal Code and conditions set
forth on the permit and understands that failure to comply may result in permit revocation and/or civil
penalties.
Signed: ___________________________ Title: _______________________________
Print Name: _______________________
DO NOT USE THIS SPACE
Approved By:
TM: ____________________
CEA: ___________________
Approval Date:
____________
____________
Page 2 of 2
F:\CivilEngineeringandArchitecture\Share\CE LAND DEVELOPMENT\EXCAVATION AND WIRELESS FACILITY PERMITS PROCESS AND
PROCEDURE\Forms\Current\WIRELESS FACILITY PERMIT APPLICATION REV120619.doc