IV. DESIGN ENGINEER (IF APPLICABLE):
Location of Work:
Description of Work:
Contractor Performing Work:
(if different from Authorized
Representative listed in Section IV)
Cell Number:
Ofce Number:
Email:
Context Specic District
(Design Guidelines Section 5,
Figure 5A):
III. WORK DESCRIPTION:
II. INSTALLATION OWNER (OPERATOR/UTILITY
PROVIDER & AUTHORIZED REPRESENTATIVE):
Operator/Utility Provider Name
(Individual and Organization):
Mailing Address
(Street, City, State, ZIP):
Email and Phone Number:
Public Works | 2018
SMALL CELL RIGHT-OF-WAY PERMIT APPLICATION
I. APPLICATION TYPE: See Design Guidelines Section 2 for
further details on application types.
Type 1: Collocation on Existing Wireless Support
Structure and Associated Small Cell Facilities
Type 2: New Wireless Support Structure and
Associated Small Cell Facilities
Type 3: Removal of Wireless Support Structure and/
or Associated Small Cell Facilities
Type 4: Eligible Facilities Request
This is the Small Cell Right-of-Way Permit application form for all Small Cell Facilities and Wireless Support Structures proposed to be
located within or removed from the City of Dublin Right-of-Way. In addition to this application, applicants should submit the completed
Small Cell Wireless Application checklist, along with the specic requirements for each application type indicated below. Applicants may
attach additional sheets if necessary.
For questions or more information, please contact Engineering at 614.410.4740 ׀ www.dublinohioUSA.gov
Historic Dublin
Bridge Street District
Residential District
West Innovation District
Other Business Neighborhoods/
Commercial Districts
Name (Individual and Organization):
Email and Phone Number:
Emergency Number:
General Right-of-Way
Permit Number:
List Subcontractor Company(ies):
**In accordance with O.R.C. section 4939.031(E), an Agent who is
performing the specic work described in Section III on behalf of
an Operator must, at the time of ling the Small Cell Right-of-Way
Permit Application and attached hereto, provide the City with written
authorization from the Operator to perform such work on its behalf.
Authorized Representative**
(if applicable):
Mailing Address
(Street, City, State, ZIP):
Email and Phone Number:
Emergency Number:
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
Page 2 of 2
V. APPLICANT DECLARATIONS: This section must be completed with an original signature of Applicant [For the purpose of this specic
declaration, the Applicant who afrms must be an Operator as dened 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.
4.
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 trafc controls prior to start of work in conformity with the Ohio Manual on Uniform Trafc Control Devices. The
City Engineer reserves the right to alter, change or modify trafc 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 indemnies 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 ofcial Small Cell Right-of-Way Permit issued by the City.
Send completed applications to rightofway@dublin.oh.us or City of Dublin, Engineering, 6555 Shier Rings Road, Dublin, Ohio, 43016
For the purpose of this specic declaration, the Applicant who afrms must be an Operator as dened by O.R.C. Sec 4939.01(k).
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