Fillable LICATION FRANCHISE AGREEMENT APP (City of Liberty Lake)

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LICATION FRANCHISE AGREEMENT APP (City of Liberty Lake)

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The LICATION FRANCHISE AGREEMENT APP (City of Liberty Lake) form is 2 pages long and contains:

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  • 8 check-boxes
  • 26 other fields

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File type: PDF

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02/25/2019 Page 1 of 2
Initial Application Renewal
Along with this application please provide the following:
o A detailed map indicating scope of work, boundaries, and a proposed time schedule for installation of equi
pment,
facilities, and other improvements necessary to become operational.
o
A description of the method of construction of the proposed system (i.e. boring, trenching, overhead, structu
re
mounted, etc.
)
.
o
A detailed statement describing the transmission medium and physical facility proposed, techni
cal design, the
actual e
quipment, and the operational and technical standards used as the basis for design.
o For renewals: in addition to the items listed above, provide a map indicating the location of existing equipm
ent
and/or fa
cilities located within the public right-of-way.
Please note that there is a $2,500.00 charge for Franchise Agreements.
All businesses which are located in, or perform work in the City, must have a current WA State Business License
with a City of Liberty Lake Endorsement.
Applicant Information
Company Name:
Address: City, State, Zip:
Name of Primary Contact: Phone:
Email:
Statement of Or
g
anization
Please describe in detail, the corporate or other business organization, including parent and subsidiaries of the applicant
company, and any business names previously used for the organization (by acquisition or buy-out).
Have you, or any person or entity controlling the applicant company, been adjudged bankrupt or had
a franchise revoked?
Yes No
Have you, or any person or entity controlling the applicant company, been found guilty by any court
or administrative agency of a violation of a security or antitrust law, federal or state safety laws or
re
g
ulations, or an
y
felon
y
?
Yes No
If you answered yes to either question above, please identify any such person and provide an explanation of the
circumstances.
Proposed Plan
Estimated Above Ground Mileage: Estimated Below Ground Mileage:
Projected Total Cost for Construction: Estimated Time Frame of Completion:
(continued on next page)
FRANCHISE AGREEMENT APP
LICATION
Liberty Lake Planning, Engineering & Building Services
22710 E Country Vista Drive, Liberty Lake, WA 99019
Phone: (509) 755-6726 Fax: (509) 755-6713
Website: www.libertylakewa.gov
Email: permitcenter@libertylakewa.gov
02/25/2019 Page 2 of 2
Describe in detail the services you expect to provide within the City, including whether the provision of services will be to
commercial and/or residential customers.
What licenses, certificates, and authorizations are required from the Federal Communications Commission (FCC), the
Federal Energy Regulatory Commission (FERC), the Washington Utilities and Transportation Commission, and any other
federal or state agency with jurisdiction over the proposed activities?
Have all licenses, certifications, and authorizations listed above been obtained?
Yes No
Previous Experience
(If requested by the City, please complete the portion below for all other franchise agreements awarded to the applicant, its parent or subsidiary. Attach
additional pages as needed.)
Location of Awarded Franchise: Date:
Completion Status: Cost of Completion:
Please describe the scope of work and the amount of resources committed to the project:
Location of Awarded Franchise: Date:
Completion Status: Cost of Completion:
Please describe the scope of work and the amount of resources committed to the project:
BY SIGNING
BELOW, I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE.
Applicant's Signature (REQUIRED) Printed Name Date
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LICATION FRANCHISE AGREEMENT APP (City of Liberty Lake)

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Completed 3 August 2020

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