Fillable Small Cell Technology Facility Application (City of Gulfport Mississippi)

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Small Cell Technology Facility Application (City of Gulfport Mississippi)

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Proposed Small Cell Technology / Facility
will be placed on a: New Support Structure ** Existing Support Structure
Name of Contractor Doing Construction/Installation:____________________________________________________________________
Contractor Address:_________________________________City:_________________________State: __Zip Code:_______________
Contractor Contact Person:________________________Title with Contractor:_________________Office Phone No.:________________
Contractor Contact E-Mail:________________________________Contractor Contact Mobile No.:________________________________
* Any work occurring in City Right-of-Way is required to be the subject of a permit obtained in accordance with the
City’s “Street Trenching and Right-of-Way Management Ordinance” (Section 7-250, et seq. of the City of Gulfport’s
Code of Ordinances).
Date Submitted:_____________________________ Application #:______________________
Customer Project ID #:_______________________
NOTE: This Application is for a permit under the City of Gulfport’s “Ordinance Adopting Regulations for Small Cell Technology,
Infrastructure, and Facilities in the City of Gulfport, Mississippi.” All parts and portions must be completely and accurately
filled out, as this will affect a timely and proper review of the Application. Applications are reviewed by the Director of
the City’s Department of Urban Development or his/her designee, subject additionally to the City’s Planning Commission
(for new Support Structures) and Building Code and construction permitting processes. The Director may also rely on a
review by other City Departments as needed or necessary. Provide two (2) complete sets of drawings and
supporting documents per location.
Applicant’s Full Legal Name:_________________________________________________________________________________________
Applicant’s Mailing Address: City:________________________State: __Zip Code:_______________
Applicant’s Physical Address: City:________________________State: __Zip Code:_______________
Contact Person:________________________Title/Connection with Applicant:_________________Office Phone No.:_________________
Contact Person Mailing Address:_______________________________City:______________________State: __Zip Code:__________
Contact Person E-Mail:_______________________________________Contact Person Mobile No.:________________________________
SMALL CELL TECHNOLOGY
FACILITY PERMIT APPLICATION
Proposed Small Cell Technology / Facility is located: On Private Property On City Right-Of-Way / On City Property
Not in the Right-of-Way *
If any work is to occur in a City Right-of-Way, an application for a permit under Section 7-250, et seq. of the City of Gulfport’s Code of
Ordinances (“Street Trenching and Right-of-Way Management Ordinance”) is required to be submitted to the City’s Urban
Development Department. Has such an application been submitted? YES NO
** Wireless small cell facilities that are located on new support structures are required to obtain Planning
Commission approval prior to the issuance of a small cell technology facility permit.
If a wireless small cell facility is to be located on a new support structure, an application for Planning Commission approval must be
submitted to the City’s Planning Commission. Has such an application been submitted? YES NO
Page 2
ACKNOWLEDGMENT
PURSUANT TO THE SMALL CELL TECHNOLOGY FACILITY ORDINANCE, THE FOLLOWING ITEMS MUST MINIMALLY BE
ATTACHED TO THIS APPLICATION (IF REQUIRED) (SEE SECTION 4 OF ORDINANCE):
Attached (1) A list of names, addresses, telephone numbers, and e-mail addresses of all duly authorized representatives and
consultants, if any, acting on behalf of the applicant with respect to the filing of this Application.
Attached (2) A general description of the equipment, the technology (including, for example, spectrum usage and transmitter
power) and the services to be provided by the proposed facilities.
Attached (3) Site plans and drawings stamped by a duly licensed engineer for each facility depicting the type of facilities,
support structure(s), and means and points at which such facilities associated accessory equipment will be
attached to a support structure, and a loading analysis statement. These drawings and site survey should be
drawn to scale and show existing City utilities (water/sewer/drainage) and any other items on site necessary for
City review.
Attached (4) Map(s) designating with specificity the location(s) of the requested facilities and all other existing or proposed
locations within 1,000 feet.
Attached (5) The geographic coordinates of all antenna(s) and other proposed facilities within 1,000 feet.
Attached (6) If the facilities will be located within rights-of-way on a support structure that is owned by any entity other
than the City or the applicant, a copy of any license, lease, agreement, letter or other documentation
evidencing that the owner of that support structure authorizes the facilities to be attached thereto or agrees
in principle to authorize that attachment must be provided. Failure to provide this documentation is alone
grounds for denial of a permit.
Attached (7) If the applicant requests permission to place facilities on a new support structure, include the
documentation required by this Ordinance to justify a new support structure (for example, documents to
show compliance with other requirements contained in this Ordinance shall be met, including, but not
limited to, applying for approval from the City’s Planning Commission).
Attached (8) Photo-simulated post-construction renderings depicting the proposed facilities and equipment, including an/all
equipment cabinets, ancillary structures, coloration, and landscaping.
Attached (9) Copies of all required insurance forms (per section 4(D) of the Small Cell Technology Facility Ordinance).
Attached (10) Franchise agreement (if required).
By signing this Application, the undersigned (contact person for the Applicant herein) states and affirms that he/she has been duly authorized
by the Applicant to submit this Application on its behalf, to act on behalf of the Applicant in connection with this Application, and to bind the
Applicant with respect to the representations and statements made in this Application. In addition, the Applicant and undersigned person on its
behalf hereby state and affirm that the information contained in this Application is true and accurate and it is further acknowledged that the
Applicant must adhere to and comply with all provisions of the City of Gulfport’s “Ordinance Adopting Regulations for Small Cell Technology,
Infrastructure, and Facilities in the City of Gulfport, Mississippi” as well as any and all other City Ordinances and state and federal laws.
SIGNED AND ACKNOWLEDGED:_________________________________________________________________________
PRINTED NAME___________________________________________DATE:______________________________________
FOR OFFICE USE ONLY: Date Application Received by Director of Urban Development:___________________________________________
Reviewed By:______________________________________________ Permit Fee Amount:____________________________
Permit Approved Permit Denied Application Incomplete Date Permit Fee Received:_______________________
Permit Issue Date:__________________________________________ Permit Number:_______________________________
GPS Location of Proposed Small Cell Technology Facility: Latitude:_____________________ Longitude:____________________
Physical Address:___________________________________City:______________________State:______Zip Code:____________
Revision date 8/9/19
Page 1 of 5
If the property or properties listed above have more than one owner, please check this box. In the case
of multiple owners, reverse side must be completed. Each additional owner will need to complete
and sign the reverse side of this application. We can only accept applications with original signatures.
SECTIONS A. THROUGH G. MUST BE SUBMITTED FOR A COMPLETE APPLICATION.
CITY OF GULFPORT
Urban Development - Planning Division
1410 24th Avenue
Gulfport, MS 39501
(228) 868-5710
APPLICATION FOR
PLANNING COMMISSION APPROVAL
SMALL CELL TECHNOLOGY FACILITIES
WITH NEW SUPPORT STRUCTURES
GENERAL DESCRIPTION OF REQUEST:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
___________________________________________________
OWNERSHIP AND CERTIFICATION:
I hereby certify that I have read and understand this application and that all information and attachments are true
and correct. I also certify that I agree to comply with all applicable city codes, ordinances and state laws.
Finally, I certify that I am the owner of the property involved in this request or have authorization to act as the
owner’s agent for the herein described request.
OWNER
____________________________________
Printed Name of Owner
____________________________________
Mailing Address
____________________________________
City State Zip code
____________________________________
Home Phone Work/Cell Phone
____________________________________
Email
__________________________________________________
Signature of Owner
AGENT
____________________________________
Printed Name of Agent
____________________________________
Mailing Address
____________________________________
City State Zip code
____________________________________
Home Phone Work/Cell Phone
____________________________________
Email
__________________________________________________
Signature of Agent
For Staff Use Only
Case Number:_________________
Date Received:________________
Receipt Number:_______________
Received By:__________________
Zoning: ______________________
Ward: ________Flood:__________
Size:_________________________
Property Information
TAX PARCEL #
(If necessary, use separate sheet of paper for additional parcels or coordinates)
Address of Property Involved:_______________________________________________________________
General Location:_________________________________________________________________________
Revision date 8/9/19
Page 2 of 5
This page must be completed if the property or properties involved have more than one owner. All
persons listed as owners to the property or properties listed on page one must complete and sign this part
of the application.
I hereby certify that I have read and understand this application and that all information and attachments
are true and correct. I also certify that I agree to comply with all applicable city codes, ordinances and
state laws. Finally, I certify that I am the owner of the property involved in this request or authorized to
act as the owner’s agent for herein described request.
NAME OF OWNER (PRINT)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
PHONE # (H) (W)
TAX PARCEL NUMBER(S) OWNED
SIGNATURE:
NAME OF OWNER (PRINT)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
PHONE # (H) (W)
TAX PARCEL NUMBER(S) OWNED
SIGNATURE:
NAME OF OWNER (PRINT)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
PHONE # (H) (W)
TAX PARCEL NUMBER(S) OWNED
SIGNATURE:
(Use additional forms as needed)
IN CASES OF MULTIPLE APPLICANTS, PLEASE IDENTIFY THE PERSON WHO WILL BE ACTING AS YOUR SPOKES
PERSON/AGENT FOR YOU:
Revision date 8/9/19
Page 3 of 5
IMPORTANT NOTICE
1. Please be advised that failure to submit a complete
application, with all supporting documents, could delay
your hearing date. The Planning Commission will not
consider a request until all information is submitted and
accurate.
2. Please be advised that the application deadline dates
posted are designed to allow the staff time to review the
application and receive required comments from
coordinating agencies. The application is not considered
complete until all required information from the
applicant is available for review by the staff and
coordinating agencies.
3. Please see reverse of this sheet to determine the
deadline dates for filing your application.
All dimensions of buildings, structures,
Facilities, antennas, support structures,
enclosures and accessory equipment
have been noted on the site plan;
All distances from the property lines to
all the buildings, structures, Facilities,
antennas, support structures, enclosures
and accessory equipment have been
identified and noted on the site plan. If in
rights-of-way, distance to property lines
and edge of pavement of paved roads;
Street names have been provided which
abut the property;
Traffic flow, parking and driveways have
been identified;
Required buffer strips have been
identified;
Other pertinent information as needed to
pictorially demonstrate the proposed
development/use;
E. Color Elevations. Please note that approval of
your request, in part, is based on the following:
Color and material of Facility, antennas,
support structure, enclosures and
accessory equipment;
Overall height of every building,
structure, Facilities, antennas, support
structures, enclosures and accessory
equipment, measured from closest
adjacent grade;
Height of Facilities, measured from
closest adjacent grade;
Detailed elevation on all sides;
Photo-simulated post-construction
renderings depicting the proposed
Facilities and equipment, including any
and all Accessory Equipment, equipment
cabinets, ancillary structures, coloration,
and landscaping;
F. Provide a list of all adjacent structures and
buildings and their overall height above
closest adjacent grade;
G. Photos of the area in which the Facilities are
proposed for placement, including
surrounding buildings, properties and uses;
SUBMISSION REQUIREMENTS
A. Page one of this application, completed and
signed;
B. A general description of the equipment, the
technology (including, for example, spectrum
usage and transmitter power) and the services to
be provided by the proposed Facilities;
C. A notarized statement that the proposed DAS
and/or Small Cell Technology Facility (and
associated Accessory Equipment) shall comply
with all applicable codes and regulations;
D. Site plan. Please note that approval of your
request, in part, is based on your site plan;
The geographic coordinates of all
antennas and other proposed Facilities of
the Applicant included in the
Application;
The property lines and dimensions have
been provided on the drawing;
All buildings, structures, Facilities,
antennas, support structures, enclosures
and accessory equipment located on the
property have been identified;
Revision date 8/9/19
Page 4 of 5
H. Map(s) designating with specificity the location(s)
of the requested Facilities and all other existing or
proposed locations of the application by the
Applicant within 1,000 feet. If none are located
within 1,000 feet, provided notarized letter that
there are no small cell technology Facilities and
support structures located within 1,000 feet;
I. The Applicant must have provided the City written
evidence that no reasonable collocation opportunity
exists. This documentation shall include, but not be
limited to, affidavits, correspondence, or other
written information that demonstrates that the
Applicant has taken commercially reasonable
actions to achieve collocation in the requested
location or area, that the Applicant has pursued but
been denied access to all potential collocation sites
in the subject area (and the reasons for any such
denial(s)), and otherwise show that the Applicant is
unable to collocate on an existing Support
Structure, including for technical and other valid
reasons;
J. Proof of ownership (Copy of deed or affidavit);
K. If applicable, notarized proof of authority to act as
agent for owner (board resolution, etc.);
L. If the Facilities will be located within the Rights-
of-Way on a Support Structure that is owned by
any entity other than the City or the Applicant and
which was located or situated there with authority
from the City, a copy of any license, lease,
agreement, letter or other documentation
evidencing that the owner of that Support Structure
authorizes the Facilities to be attached thereto or
agrees in principle to authorize that attachment;
M. Notarized statement from the applicant that the
proposed installation will not cause harm to the
public or pose any undue risk to public safety and
provide supporting documentation (e.g., through a
means of industry certified reports for EME
exposure limits or disruption of visual site triangles
related to traffic, etc.);
N. If the proposed installation will disturb conditions
on the Rights-of-Way, provide a notarized
statement attesting whether the applicant has the
ability and financial resources to restore the subject
area to its preexisting condition following
installation. The statement should also mention the
Rights-of-Way shall be restored to its pre-existing
condition by Applicant/Permittee following any
installation or construction;
O. The City of Gulfport Planning Division Staff
will notify, by letter, property owners adjacent
to the requested action identified in this
application using the Land Roll database from
the County Tax Office. If you would like to
have additional persons or property owners
notified, please provide a list of additional
persons to be notified;
P. Provide a written statement addressing the
following issues by explaining how the site
plan is appropriate with regard to why the
proposal is in harmony with the orderly and
appropriate development of the district in
which the use is located.
Revision date 8/9/19
Page 5 of 5
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Small Cell Technology Facility Application (City of Gulfport Mississippi)

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Completed 15 July 2020

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