Fillable City of Rockford, Illinois (CITY OF ROCKFORD)

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City of Rockford, Illinois (CITY OF ROCKFORD)

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City of Rockford, Illinois
Public Works Department
425 East State Street, Rockford, IL 61104
Phone: 779-348-7174 Fax: (815) 967-7058
Web: www.rockfordil.gov
Page | 1 of 4
SMALL WIRELESS FACILITIES PERMIT APPLICATION
(ENCROACHMENT LOCATED WITHIN THE CITY RIGHT-OF-WAY)
APPLICANT INFORMATION
Applicant Name:
Date:
Applicant is a: ⃣ Carrier/Wireless Provider ⃣ Representative ⃣ Other:
Company Name:
Address:
City:
State:
ZIP Code:
Phone:
Email:
PROPOSED SITE LOCATION
Property Address:
City:
State:
ZIP Code:
Closest Intersection (Distance and Direction from):
EXISTING POLE/STRUCTURE INFORMATION
New Pole/Structure Construction? Yes ⃣ No ⃣
Pole/Structure ID Number:
Height of Pole/Structure (feet):
Pole Color:
Existing Attachment(s) on Pole/Structure? (
e.g.
, banners, light fixtures) Yes ⃣ No ⃣
Existing Structure Owner:
Name of Structure Owner Representative:
Address:
City:
State:
ZIP Code:
Phone:
E-mail:
Fax:
PROPERTY OWNER INFORMATION
In the event that the proposed small wireless facility is to be attached to an existing pole owned by an entity other
than the City, the wireless provider shall provide legally competent evidence of the consent of the owner of such pole
to the proposed collocation. Permission has been granted by property owner? Yes ⃣ No ⃣
Name:
Address:
City:
State:
ZIP Code:
Phone:
Email:
City of Rockford, Illinois
Public Works Department
425 East State Street, Rockford, IL 61104
Phone: 779-348-7174 Fax: (815) 967-7058
Web: www.rockfordil.gov
Page | 2 of 4
APPLICATION REQUIREMENTS
The following documents must be attached or included for the Application to be complete:
⃣ Application fee(s)
⃣
Site specific structural integrity, AND for a municipal utility pole
⃣ Make-ready analysis prepared by a structural engineer
⃣
The location where each proposed small wireless facility or utility pole would be installed
⃣ Photographs of the proposed site location and its immediate surroundings
⃣ Specifications and drawings prepared by a structural engineer for each proposed small wireless facility
⃣ The equipment type and model numbers for the antennas and all other wireless equipment associated with the
small wireless facility
⃣ A proposed schedule for the installation and completion of each small wireless facility, if approved
⃣ Proof of permission granted by property owner, if existing pole not owned by the City
ATTESTATION, ACKNOWLEDGMENT & SIGNATURE
I attest to the best of my knowledge and belief, that the information stated in this application and in all supporting
plans and documents is true and accurate. To the best of my knowledge, I certify that the proposed collocation
complies with the terms of the “Collocation Requirements and Conditions” Section of [CITY/VILLAGE]’s Small Wireless
Facility Deployment Ordinance.
Date:
Printed Name of Applicant:
Title:
**FOR ADMINISTRATIVE USE ONLY**
Date Application was submitted:
Application is: ⃣ Complete ⃣ Incomplete
If incomplete, date the Applicant was notified:
Missing documents or information:
City of Rockford, Illinois
Public Works Department
425 East State Street, Rockford, IL 61104
Phone: 779-348-7174 Fax: (815) 967-7058
Web: www.rockfordil.gov
Page | 3 of 4
This Agreement is date as of the ______ day of ___________, 20____, by and between the CITY OF ROCKFORD, a
municipal corporation, (“City”), and _________________________________ (“Participant”).
RECITALS:
WHEREAS, the Participant wishes to install an encroachment in the City of Rockford right-of-way; and
WHEREAS, the City wishes to permit such installation to encourage the beautification of the community, subject to the
terms and conditions herein.
NOW, THEREFORE, IT IS AGREED AS FOLLOWS:
1. Installation. Participant will install the following:
# and Type description of encroachment(s)
_________ ________________________ ______________________________________________________
_________ ________________________ ______________________________________________________
_________ ________________________ ______________________________________________________
_________ ________________________ ______________________________________________________
LOCATED AT: ___________________________________________________________________________________
(List street address or corner and ROW description, i.e. median, sidewalk, etc.)
Upon obtaining a permit to do so by the Department of Public Works. Participant agrees to abide by any conditions contained in
the permit.
2. Maintenance. Participant agrees to maintain the encroachment, including weeding, watering and repairs.
Participant agrees to maintain the encroachment in a clean and safe condition in the location approved.
3. Indemnification, Duty to defend, and Hold Harmless, To the fullest extent permitted by law, Participant
agrees to that it shall indemnify and hold harmless the CITY OF ROCKFORD, a municipal corporation, and its officers, agents,
representatives and/or employees from and against any and all claims, suits, liens, judgments, damages, losses and expenses,
including legal fees and all court costs and liability (including statutory liability) arising in whole or in part and in any manner
from injury and/or death of person or damage to or loss of any property resulting from the acts, omissions, breach or default of
Participant and any of its officers, agents, employees, members or volunteers, that occur while acting on behalf of Participant
while installing or maintaining the encroachment, in connection with the performance of any work under this agreement, by or for
Participant pursuant to any contract, except those claims, suits, liens, judgments, damages, losses and expenses caused by the
negligence of the City of Rockford. Participant will defend and bear all costs of defending any actions or proceedings brought
against the City of Rockford, a municipal corporation, and its officers, agents, representatives and/or employees, arising in whole
or in part from any such acts, negligence, reckless or willful misconduct, omission, breach or default directly or indirectly, by
Participant in the construction, existence, maintenance, or repair of the aforementioned encroachment.
4. City's Remedies for Noncompliance. If in the opinion of the City Engineer or his designee the
encroachment(s) are not being maintained as required by this Agreement, the issued permit, and any applicable laws or
regulations, the City Engineer or his designee may, upon notice described below, either: a. remove the encroachment, or b. elect
to maintain the encroachment, but may subsequently remove with no further notice required. The City shall not be liable to the
Participant in any way for said removal or takeover, and shall not be required to return the encroachment to the Participant. Prior
to taking such action the City Engineer or his designee shall notify Participant of the maintenance deficiency in writing at the
address herein or at such address Participant has designated in writing to the City as Participant's current address. The notice shall
advise the Participant that the Participant has fourteen (14) days to correct the deficiency.
City of Rockford, Illinois
Public Works Department
425 East State Street, Rockford, IL 61104
Phone: 779-348-7174 Fax: (815) 967-7058
Web: www.rockfordil.gov
Page | 4 of 4
5. Notices. All notice, requests, demands and other communication (collectively “Notices”) hereunder shall be
in writing and given by personal delivery or U.S. mail, postage prepaid, at the following addresses or at such other addresses as
the parties may designate by Notice given in the above-described manner:
City:
Participant:
CITY OF ROCKFORD
Name:
Department of Public Works
Address:
City Engineer
425 E. State Street
Rockford, IL 61104
Notice of suit or claim to:
CITY OF ROCKFORD
Legal Director
425 E. State Street
Rockford, IL 61104
Notice shall be effective upon receipt or upon attempted delivery if delivery is refused or impossible because the recipient has
failed to provide a reasonable means for accomplishing delivery.
IN WHITNESS WHEREOF, the City and Participant have executed this Agreement on the date above first written.
CITY OF ROCKFORD PARTICIPANT
By: ______________________________ ______________________________
City Engineer
Org. ______________________________
Title. ______________________________
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Completed 25 February 2021

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