Fill - Free fillable Personal Wireless Service Facility Application (City of Kirkland) PDF form

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Innovative - Responsive - Professional

Personal Wireless Service

Facility Application

Planning Department

Complete this form to submit at City Hall. Or, use mybuildingpermit.com to submit your application entirely online.

This permit application packet is designed to obtain all the information necessary to allow the City to make a well-

informed decision on your application. Please refer to the attached application checklist to determine the materials

which must be submitted to complete your application. All application materials are public information.

Your application will be evaluated on the basis of the information you provide, the criteria listed in the pertinent

sections of the Subdivision Ordinance, the Kirkland Comprehensive Plan, other City regulatory ordinances, inspection of

the property, as well as public comments.

YOU ARE ENCOURAGED TO MEET WITH A PLANNER FROM THE PLANNING AND BUILDING DEPARTMENT PRIOR TO AND

DURING PROJECT DESIGN TO DISCUSS PROJECT COMPLIANCE WITH CITY REGULATIONS. YOU MUST MEET WITH A

PLANNER TO OBTAIN GUIDANCE ON THE APPLICATION MATERIALS YOU MUST SUBMIT.

Copies of City ordinances such as the Comprehensive Plan, Zoning Ordinance, Subdivision Ordinance, and Shoreline

Master Program are available at the Planning and Building Department in City Hall, 123 Fifth Avenue; and the Kirkland

Public Library, 308 Kirkland Avenue. To purchase the Comprehensive Plan or Zoning Ordinance, call Code Publishing

Company at (800) 551-2633. The City ordinances

can also be found online.

As a result of your application, you may be required to make improvements such as sidewalks, curbs, street trees, or

utilities undergrounding within the rights-of-way abutting your property. Please refer to Chapter 110

of the Zoning

Ordinance and/or consult with a planner to determine if this is the case.

Zoning Code Chapter 117 regulates Personal Wireless Service Facilities (PWSF) in the City of Kirkland. A new or

replacement PWSF may be allowed through a Planning Official decision, Process I, Process IIA or Process IIB. The review

process is determined by the type and location of the proposed PWSF, pursuant to Kirkland Zoning Code Chapter

117.40. In some cases, a SEPA checklist and/or public notice is required.

NOTE: Information provided by the Department of Planning and Community Development represents a preliminary,

qualified assessment which is based on the information provided by the applicant/contact person. More

detailed technical review of a specific development permit application may disclose additional substantive or

procedural requirements. Furthermore, in the case of a short plat, the role and the authority of the Planning

and Building Department staff is advisory only. A final decision only is made, after public comment, by the

Planning Director.

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Personal Wireless Service Facilities (PWSF) Application - continued

Planning Official Process I Process II Process IIB Modification

UBN

Wireless company (legal name as applicant):

Primary Contact Person

Name

Address

City State Zip Code

Daytime #

Alternate #

Prefer written correspondence by email provided. Prefer written correspondence by address provided.

Secondary Contact Person

Name

Address

City

State

Zip Code

Daytime #

Alternate #

Prefer written correspondence by email provided. Prefer written correspondence by address provided.

AN ELECTRONIC COPY OF OR A WEB LINK TO THE STAFF REPORT, MEETING AGENDAS AND THE NOTICE OF FINAL DECISION WILL BE

EMAILED TO THE APPLICANT AT THE ABOVE LISTED ADDRESS. IF YOU PREFER TO RECEIVE A PAPER COPY, THEY ARE AVAILABLE

UPON REQUEST. PLEASE INDICATE IF YOU WOULD ALSO LIKE A COPY OF THESE MATERIALS TO BE SENT TO THE PROPERTY

OWNER'S EMAIL ADDRESS:

Yes, please send the owner a copy. No, don't send the owner a copy.

Site Information

Site Address Parcel #

The site is zoned and is presently used as

Describe permit application and the nature of project (attach additional pages, if necessary):

List all previous permits for the subject property. If you are applying to replace a PWSF, identify the permit that

approved the PWSF to be replaced.

Has the property been subdivided before?

Yes No

If so, what is the Planning Department permit number?

Have you met with a planner prior to submitting your application?

Yes No

Name of Planner Date of pre-submittal meeting

Pre-submittal case Number

Note: If applicant is not property owner, he/she must be authorized as agent (see page 2).

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AUTHORITY TO ENTER PROPERTY

I/we acknowledge that by signing this application I/we are authorizing employees or agents of the City of Kirkland to

enter onto the property which is the subject of this application during the hours of 7:00 a.m. to 5:00 p.m., Monday

through Friday, for the sole purpose of making any inspection of the limited area of the property which is necessary to

process this application. In the event the City determines that such an inspection is necessary during a different time or

day, the applicant(s) further agrees that City employees or agents may enter the property during such other times and

days as necessary for such inspection upon 24 hours notice to applicant(s), which notice will be deemed received when

given either verbally or in writing.

HOLD HARMLESS AGREEMENT READ CAREFULLY BEFORE SIGNING

The undersigned in making this application certifies under penalty of perjury, the truth and/or accuracy of all

statements, designs, plans and/or specifications submitted with said application and hereby agrees to defend, pay, and

save harmless the City of Kirkland, its officers, employees, and agents from any and all claims, including costs, expenses

and attorney's fees incurred in investigation and defense of said claims whether real or imaginary which may be

hereafter made by any person including the undersigned, his successors, assigns, employees, and agents, and arising

out of reliance by the City of Kirkland, its officers, employees and agents upon any maps, designs, drawings, plans or

specifications, or any factual statements, including the reasonable inferences to be drawn therefrom contained in said

application or submitted along with said application.

I certify that I am the owner of this property or the owner's authorized agent. If acting as an authorized agent, I further

certify that I have full power and authority to file this application and to perform, on behalf of the owner, all acts

required to enable the jurisdiction to process and review such application. I have furnished true and correct

information. I will comply with all provisions of law and ordinance governing this type of application. If the scope of

work requires a licensed contractor to perform the work, the information will be provided prior to permit issuance.

With respects to this application, we designate to act as our agent:

The undersigned property owners, under penalty of perjury, each state that we are all of the legal owners of the

property described on the short plat map.

YOU MAY NOT BEGIN ANY ACTIVITY BASED ON THIS APPLICATION UNTIL A DECISION INCLUDING THE RESOLUTION

OF ANY APPEAL, HAS BEEN MADE. CONDITIONS OR RESTRICTIONS MAY BE PLACED ON YOUR REQUEST IF IT IS

APPROVED. AFTER THE CITY HAS ACTED ON YOUR APPLICATION, YOU WILL RECEIVE FORMAL NOTICE OF THE

OUTCOME. IF AN APPEAL IS FILED, YOU MAY NOT BEGIN ANY WORK UNTIL THE APPEAL IS SETTLED. YOU MAY ALSO

NEED APPROVALS FROM OTHER CITY DEPARTMENTS. PLEASE CHECK THIS BEFORE BEGINNING ANY ACTIVITY.

If you suspect that your site contains a stream or wetland or is adjacent to a lake; you may need a permit from the state

or federal government.

STATEMENT OF OWNERSHIP/DESIGNATION OF AGENT

YOUR APPLICATION WILL NOT BE COMPLETE UNTIL ALL DOCUMENTS LISTED ON THE APPLICATION CHECKLIST ARE

SUBMITTED.

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Facility Owner

Name

Address

City State Zip Code

Phone

Signature:

Registered Agent, Licensed in Washington State (other than applicant)

Name

Address

City State Zip Code

Phone

Signature:

Applicant

Name

Address

City State Zip Code

Daytime #

Alternate#

Signature:

Owner 1

Name

Address

City State Zip Code

Daytime #

Alternate #

Signature:

Alternate Formats: Persons with disabilities may request materials in alternative formats. Persons with

hearing impairments may access the Washington State Telecommunications Relay Service at 711.

Title VI: Kirkland's policy is to fully comply with Title VI of the Civil Rights Act by prohibiting discrimination

against any person on the basis of race, color, national origin or sex in the provision of benefits and services

resulting from its programs and activities. Any person who believes his/her Title VI protection has been

violated, may file a complaint with the City.

To request an alternate format, file a complaint or for questions about Kirkland's Title VI Program, contact the

Title VI Coordinator at 425-587-3011 or titlevicoordinator@kirklandwa.gov.

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Exhibit A: Legal Description

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