Fillable Applicant (Town of Ashland, VA)

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Applicant (Town of Ashland, VA)

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The Applicant (Town of Ashland, VA) form is 3 pages long and contains:

  • 2 signatures
  • 5 check-boxes
  • 155 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Ashland, VA

BROWSE TOWN OF ASHLAND, VA (VA) FORMS

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Page 1 of 3 (2019)
Applicant
Name: ________________________________________ Phone: _________________________
Company: ____________________________________ Email: ___________________________
Address: _____________________________________________________________________________
Wireless Service Provider: ________________________________________________________
Number of small cell facility locations included in this application: _________.
**Note: If more than one, attach a separate sheet showing the information for each location**
Existing Structure Owner/Information
Name: ________________________________________ Phone: _________________________
Company: ____________________________________ Email: __________________________
Address: ________________________________________________________________________
Structure Type: ____ Utility Pole ____ Telecommunications Pole ____ Other _______________
(specify)
Structure/Pole ID#: _____________________ GIS Coordinates: __________________________
Structure Height: __________________ Antenna Size(s): FT._______ IN._________
Structure/Pole is on: _____ private property ______right of way
Signature Required:
Applicant
X._________________________________________________ Date: _____________
If a legal representative signs for a property owner, please attach an executed power of attorney.
Owner of Existing Structure if Co-Locating of the small cell facility on the structure.
X._________________________________________________ Date: _____________
If a legal representative signs for the structure owner, please attach an executed power of attorney.
T o w n o f A s h l a n d
Small Cell Wireless
Permit
Date: ________________ Case#: _______________
Project Name: ________________________________
Department of Planning and Community Development
101 Thompson Street Ashland, Virginia 23005
Phone: (804) 798-1073 www.ashlandva.gov
Fax: (804) 798-4892
Fee TO BE COMPLETED BY STAFF ONLY
$100 each for up to five + $50 for each additional (Maximum of 35 per application)
Amount Paid: ______________ Date: __________________ X. ______________________________
Zoning Administrator Approval X. _____________________________________________________
Public Works Approval X. _____________________________________________________________
Assistant Town Manager Approval X. __________________________________________________
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Page 2 of 3 (2019)
Prior to submitting any Small Cell Wireless Permit application, the applicant is
strongly encouraged to meet with staff for a pre-application meeting by calling
(804) 798-1073.
1. Application is submitted to Town and reviewed for completion.
2. Small Cell Wireless application distributed for review to Town officials.
3. Comment letters generated by officials of the Town of Ashland.
4. If approved, contact Town to coordinate pre-construction meeting and
release permit.
TOWN SMALL CELL WIRELESS CHECKLIST
Applicant
Initials
Required information
1. GENERAL
Applicant Name, address, email, phone listed
Wireless Service Provider listed
Number of Small Cell Facility locations listed
Name address, phone and email of the owners of record
Structure Type, ID#, GIS Coordinates, height specified
Antenna Size in feet and inches specified
Signature of Applicant
Executed power of attorney for applicant if applicable
Signature of Owner of existing structure if applicable
Executed power of attorney for owner if applicable
Fee paid
2. Compliance
Each antenna is located inside an enclosure of no more than six (6) cubic feet in
volume, or, in the case of an antenna that has exposed elements, the antenna and
all its exposed elements could fit within an imaginary enclosure of no more than six
(6) cubic feet.
All other wireless equipment associated with the facility has a cumulative volume of
no more than twenty-eight (28) cubic feet of such higher limit as is established by the
Federal Communication Commission.
If applicable, permission from the owner of the structure to co-locate equipment on
that structure has been granted
Upon review, the application form may require certification by the applicant that
the small cell facility will not materially interfere with or degrade any existing public
safety communications system.
Page 3 of 3 (2019)
Structure/Pole ID#
GIS Coordinates
Structure
Height
Antenna Size
(Feet & Inches)
Private
Property
Right
of Way
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Applicant (Town of Ashland, VA)

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Completed 14 January 2021

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