City of Sumner
Wireless Facility
Application
(Please fill out ALL fields unless otherwise noted)
Supporting Materials Required:
Office Applicant - (please check off all “applicant” boxes)
This Application Form and Checklist
Site Plan 1 - Copy (8.5” x 11”)
4 - Full Sheet (24” x 36”)
◊ Building envelope with building setbacks
◊ Environmental constraints delineated
◊ Streets in relationship to the proposed structure
◊ Location of easements (if any)
◊ Stormwater/open space locations
◊ Location of fire hydrants
◊ Fire access lanes
SEPA (If required – Please consult Staff)
Cover letter addressing criteria of 2 - Copies
SMC 18.37.020 or 18.37.030 as appropriate
Structural Design and Calculations 4 - Full Sheet (24” x 36”)
Total valuation of the project - REQUIRED $______________________
Site/Project Address (if available): P
arcel #:
Owner: Phone: Email:
Owner Address: City: State: Zip:
Surveyor/Engineer/Contractor: Phone: Contractor License Number:
Address: Email: City: State: Zip:
Contact Person: Phone: Fax:
Contact Address: Email: City: State: Zip:
Description of Project:
Community Development
1104 Maple Street, Suite 250
Sumner, WA 98390
Tel. (253)299-5530 Fax: (253)299-5539
www.ci.sumner.wa.us
File Number: __________________________
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL
PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN
OR NOT.
**BY LEAVING THE CONTRACTOR INFORMATION SECTION BLANK, I HEREBY CERTIFY FURTHER THAT CONTRACTORS (GENERAL OR
SUBCONTRACTORS) WILL NOT BE HIRED TO PERFORM ANY WORK IN ASSOCIATION WITH THIS PERMIT. (building permits only)
_______________________________________________________
______________________________________________ DATE: ______/_____/_____
SIGNATURE OF OWNER / AUTHORIZED AGENT PRINTED NAME
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signature
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