I (and/or my authorized agent) will maintain the equipment proposed in this application in good operating and aesthetic conditions;
I (and/or my authorized agent) will notify the City when the equipment proposed in this application is no longer in use; and
I (and/or my authorized agent) will complete the necessary steps to remove any equipment that is no longer in use.
For questions or more information, please contact Engineering at 614.410.4740 ׀ www.dublinohioUSA.gov
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V. APPLICANT DECLARATIONS: This section must be completed with an original signature of Applicant [For the purpose of this specic
declaration, the Applicant who afrms must be an Operator as dened by O.R.C. Sec 4939.01(k)].
I ____________________________________________ , in submitting (or having my authorized agent submit) this Small Cell Right-of-Way Permit
Application, hereby declare the following:
Date:Original Signature of Applicant:
AN OFFICIAL PERMIT WILL BE GRANTED TO PERFORM THE DESCRIBED WORK UNDER THE FOLLOWING AGREED CONDITIONS
1. Applicant shall secure all required permits prior to starting any work in any city right-of-way.
2. Payment in full of the permit fee must accompany this form unless arrangements for billing have been approved by the City of Dublin.
3. All Contractors and Subcontractors shall be currently licensed/registered by the City of Dublin Building Standards to perform the work
described in section III.
Contractor shall notify the City Inspector at least 8 business hours prior to starting any work, as directed on the Small Cell Right-of-Way
Permit form to be issued by the City upon approval of a Small Cell Right-of-Way Permit Application, for inspection purposes.
5. Contractor shall set up trafc controls prior to start of work in conformity with the Ohio Manual on Uniform Trafc Control Devices. The
City Engineer reserves the right to alter, change or modify trafc controls before and during construction as the situation may demand
for the safe movement of vehicles, pedestrians and bicyclists. No lane closures are permitted on weekdays during the hours of 7:00 a.m.
to 9:00 a.m. and 4:00 p.m. to 6:00 p.m. unless authorized by the City Engineer.
6. Applicant hereby assumes all responsibility for work to be performed and indemnies the City of Dublin in accordance with section
99.26(G) of the City Code that may arise, directly or indirectly, from their operations within the public Right(s)-of-Way.
7. Applicant agrees to restore all areas involved in this work to a like or better condition and will abide by all applicable laws, rules and
regulations of the City of Dublin, the State of Ohio, and the federal government.
8. Applicant must meet all requirements in the Dublin City Code sections 99.20 - 99.99 and the Design Guidelines for Small Cell Facilities
and Wireless Support Structures within the Right-of-Way.
9. Any documents and materials submitted to the City including, but not limited to this application, shall become part of the public record
and may be subject to public record request(s).
10. Other conditions or regulations may be required as indicated on the ofcial Small Cell Right-of-Way Permit issued by the City.
Send completed applications to email@example.com or City of Dublin, Engineering, 6555 Shier Rings Road, Dublin, Ohio, 43016
For the purpose of this specic declaration, the Applicant who afrms must be an Operator as dened by O.R.C. Sec 4939.01(k).