Fillable Small Cell App Fillable Dcr (Commonwealth of Massachusetts)

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Small Cell App Fillable Dcr (Commonwealth of Massachusetts)

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1
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF CONSERVATION AND RECREATION
SMALL CELL LICENSE APPLICATION
For new requests starting January 2019
This Small Cell License Application (Application) is subject to the regulations at 302 CMR 19.00
for installation of Small Wireless Facilities within DCR Rights of Way. All capitalized defined
terms are set forth in the regulations. See The DCR Small Cell License Application Instructions
for further detail. If this Application is approved, the Licensee will be required to execute a
Form Small Cell License Agreement.
Please complete this Application and send it along with the required information and the
applicable fee to:
DEPARTMENT OF CONSERVATION AND RECREATION
DCR.SmallCell@mass.gov
APPLICANT, PROPOSED LICENSEE (EQUIPMENT OWNER/OPERATOR), AND INSTALLER
INFORMATION
Proposed Licensee (Equipment Owner/Operator)
1. Legal Name d/b/a
Contact Information (include name, title, mailing address, e-mail address, and telephone
numbers)
2. Authorized Signatory (ies) (who will sign the license on behalf of the equipment owner/
operator?) contact Information (include name, title, mailing address, e-mail address, and
telephone numbers):
3. Proposed Licensee (Equipment Owner/Operator) Billing Department contact Information
(include name, title, mailing address, e-mail address, and telephone numbers):
4. Proposed Licensee (Equipment Owner/Operator Legal Notice recipient(s) contact
2
information (include name, title, mailing address, e-mail address, and telephone
numbers):
5. Proposed Licensee’s Equipment, Location or System Manager (day-to-day contact after
install?) contact information (include name, title, mailing address, e-mail address, and
telephone numbers):
Applicant (if different from the Equipment Owner/Operator/ Licensee)
6. Legal Name of Applicant and Contact Information (name, title, mailing address, e-mail
address, and telephone numbers)
7. Affiliation with equipment owner/operator
consultant site acquisition company
counsel/attorney other: _______________________
8. Will there be other entities such as maintenance companies, consultants, affiliates, who
will control or have access to the owner/operator equipment?
Yes No
If yes, name such entities:
Installer/Contractor and Subcontractor(s) Information
9. Name and Title and Contact Information (name, title, mailing address, e-mail address,
and telephone numbers)
10. Name and Title and Contact Information (name, title, mailing address, e-mail address, and
telephone numbers)
11. Equipment Owner/ Operator on-site representative, if any, and Contact Information
(name, title, mailing address, e-mail address, and telephone numbers)
LOCATION, STRUCTURE AND EQUIPMENT INFORMATION
Right-of-Way Information
12. Name /City /Town:
3
13. Longitude/Latitude (use only Google Maps coordinates):
14. What else is in the Right-of-Way? (Attach information).
15. Will the Small Cell or Structure be located in an area subject to Massachusetts
Endangered Species Act or Natural Heritage and Endangered Species Protection?
Yes No
16. Will the Small Cell or Structure be located in an area subject the Massachusetts Wetlands
Protection Act?
Yes No
17. Will the Small Cell or Structure be located in, on, or within twenty feet (20’) of a Structure
or Location that is listed in the Inventory of the Archeologic and Historic Assets of the
Commonwealth?
Yes No
Structure Information
18. Will this be use of an:
Existing Structure(s), i.e., no new excavation, no disturbance of existing concrete;
use of an existing pole, use of existing conduit, existing cabinets and/or in-ground
handholds; or
New Structure(s), i.e., new excavation, new concrete, new pole, new cabinets or in-
ground handholds, new conduit installed.
19. Is the Structure owned by DCR?
Yes No
If not, who is the Structure owner/operator?
Please attach proof of collocation or attachment approval.
20. Does the Structure owner/operator have a valid permit, license from, or other agreement
with DCR allowing placement of the existing Structure?
Yes No If so, please attach a copy.
4
Proposed Equipment Information
21. Proposed Equipment Detail – Attach or include all required information.
22. What is on the existing Structure now (i.e., other users equipment, cameras, signage,
shields, banner holders, etc.) - – Attach or include all required information
23. Can the existing or new Structure support the proposed equipment? Please attach an
appropriate up-to-date structural analysis.
24. Is there existing conduit that is intact or will new conduit be required?
Yes No
For both old and new conduit, please attach conduit ground plan with length, width and
status information.
25. Will there be new cabinets, in ground handholds, etc. required?
Yes No
Please attach any reports or drawings showing Subsurface Utility Engineering reviews.
Construction and Location Rehabilitation
26. What is the proposed construction timeline? – Please attach a construction timeline with
weekly or monthly intervals.
27. Traffic Management Plan (TMP). Please submit information concerning the type of traffic
management plan to be employed for the type of work taking place.
OTHER APPROVALS AND PERMITTING
28. Please list all such other certificates, permits, licenses and approvals that will be sought
including agency or entity, type of approval required and sought, dates filed, and status.
In some cases DCR must sign off on the application as property owner. Applications
requiring such sign off shall be provided with this License Application and will be returned
to the Applicant within the review period.
Agency
Type of Approval
required and sought
Date filed
Copy of application sent
to DCR
Status
MHC
Determination letter
Dig Safe
Number
FEES
Application Fees (non-refundable):
i. For a License Application seeking to install up to five (5) Small Cells on existing
5
Structures in DCR Rights-of-Way (no new excavation, no new pole, no new in ground
conduit cabinet or in ground cabinet or handhold) the fee is $500;
ii. For a License Application seeking install more than five (5) Small Cells on existing
Structures in DCR Rights-of-Way the fee is $500 for the first 5 Small Cells plus $100 for
each additional Small Cell;
iii. For a License Application seeking to install a new Structure the fee is $1,000.
Annual Fee:
I. Licensee shall pay $270 annually to DCR for each Small Cell on DCR owned Structures.
II. Licensee shall pay $100 annually to DCR for each Small Cell on non-DCR owned
Structures.
Checks shall be made payable to the “Commonwealth of Massachusetts” for the appropriate
fee and must accompany this Application. Fees are non-refundable. Electronic payments for
annual license fees may be arranged.
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Small Cell App Fillable Dcr (Commonwealth of Massachusetts)

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Completed 18 July 2020

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