Fillable Village of Wheeling Small Wireless Facilities Permit PERMIT (Village of Wheeling)

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Village of Wheeling Small Wireless Facilities Permit PERMIT (Village of Wheeling)

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The Village of Wheeling Small Wireless Facilities Permit PERMIT (Village of Wheeling) form is 3 pages long and contains:

  • 1 signature
  • 21 check-boxes
  • 73 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Village of Wheeling

BROWSE VILLAGE OF WHEELING (IL) FORMS

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Page 1 of 3
Revised 5/10/2019 by LR
Name:
Company:
Address:
City, Zip:
24 hr Phone:
E-mail:
APPLICANT/REPRESENTATIVE
Name:
Company:
Address:
City, Zip:
24 hr Phone:
E-mail:
WIRELESS PROVIDER INFORMATION
Village of Wheeling
Small Wireless
Facilities Permit
PROPOSED SITE LOCATION
PERMIT NO.: Wireless -
Property Address:
Closest Intersection (Distance & Direction From):
Zoning District: Right-of Way Private Property
EXISTING UTILITY POLE/WIRELESS SUPPORT STRUCTURE INFORMATION
PIN (if not in the ROW):
Does the Project Involve a New Pole? Yes No Pole/Structure ID # Pole Color:
Height of Pole/Wireless Support
Structure (Feet):
Pole Type:
Existing Attachment(s) on Utility Pole/Wireless Support Structure? (e.g., banners, light fixtures)
Yes No
If yes, please specify:
Owner of Pole/Wireless Structure:
Name of Structure Representative: Address:
City, State, Zip: E-mail:
Office Phone: Cell Phone:
NOTE: If the proposed Small Wireless Facility is to be attached to an existing pole owned by an entity other than the Village, the Applicant/Wireless
Provider must, with the application, provide legally competent evidence of the consent of the Owner of the Pole to the proposed collocation.
Permission Received: Yes No
PROPERTY OWNER INFORMATION (IF PROPERTY NOT VILLAGE-OWNED RIGHT-OF-WAY)
Property Owner Name: Company:
Address: City, State, Zip:
24 hr Phone: E-mail:
NOTE: If the Small Wireless Facility is to be attached to an existing or new pole or wireless support structure located on property that is not Village-
owned right-of-way, the Applicant/Wireless Provider must provide legally competent evidence of the consent of the Private Property Owner to the
proposed collocation.
Permission Received:
CONTRACTOR INFORMATION
Name of Contractor: Type: Phone #: Email:
General:
Yes No
NOTE: All contractors performing work in the Village must be registered by the Village prior to the issuance of any permit.
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Page 2 of 3
Revised 5/10/2019 by LR
Site Street: Location (to & from):
APPLICATION CHECKLISTS AND REQUIREMENTS
Each application must be accompanied by the following to be deemed complete:
1.
Site specific structural integrity and, for a Village utility pole, make-ready analysis prepared by a structural engineer, as that term is defined in
Section 4 of the Structural Engineering Practice Act of 1989.
2.
The location where each proposed small wireless facility, utility pole or wireless support structure would be installed and digital photographs of
the location and its immediate surroundings depicting the utility poles or structures on which each proposed small wireless facility would be
mounted or location where utility poles or structures would be installed. The photographs shall include a digital photo simulation of the proposed
location providing “before and after” views, demonstrating the true visual impact of the proposed wireless facilities on the surrounding
environment.
3.
Specifications and drawings prepared by a structural engineer, as that term is defined in Section 4 of the Structural Engineering Practice Act of
1989, for each proposed small wireless facility covered by the application as it is proposed to be installed
4.
The equipment type and model numbers for the antennas and all other equipment associated with the small wireless facility.
5.
A proposed schedule for the installation and completion of each small wireless facility, utility pole and wireless support structure covered by the
application, if approved.
6.
A traffic plan, if necessary.
7.
Copies of all licenses, permits and approvals required by or from the Village (i.e. zoning approval, where required), other agencies and units of
government with jurisdiction over the design, construction, location and operation of said small wireless facility. The applicant shall maintain such
licenses, permits and approvals in full force and effect and provide evidence of renewal or extension thereof when granted.
8.
In the event the small wireless facility is proposed to be attached to an existing utility pole or wireless support structure owned by an entity other
than the Village, legally competent evidence of the consent of the owner of such pole or wireless support structure to the proposed collocation.
9.
In the event the small wireless facility is to be located on private property outside of the right-of-way, legally competent evidence of the consent
of the owner of such property to the proposed collocation.
10.
Application Fee(s).
11.
If the proposed installation includes ground-mounted equipment, compliance with any applicable Village standards, including, where required: a
landscape plan showing specific landscape materials, method of fencing, finished color and, if applicable, the method of camouflage or
concealment.
12.
Copy of existing Master Pole Attachment Agreement with the Village relative to Small Wireless Facilities, if any, if seeking to locate on a Village
owned utility pole or wireless support structure.
13.
Sufficiently detailed documentation establishing that the proposed installation will comply with all ordinances of general application pertaining
to installations in the right-of-way, right-of-way usage and the National Electric Code.
14.
Proof of minimum mandatory insurance, including self-insured retentions.
15.
The permittee shall provide the Village Engineer the name and title of at least one (1) representative with their 24 hour contract phone number in
the event that an emergency should arise. Permittee shall notify the Village of any changes to this contact.
16.
All unpaved areas of right-of-way are to be restored with four inches (4") of topsoil and sod.
17.
Work shall be limited to Monday through Saturday from 7:00 A.M. to 6:00 P.M. and no work on any Sunday, or Village Observed Holidays. Saturday
work is permitted if notification is requested and approved by Village Engineer 48 hours before work commences.
18.
The property owner bears sole responsibility for private irrigation systems constructed in the public right-of-way. The Village takes no
responsibility for repair or replacement of damaged irrigation system while performing work within the right-of-way. The contractor will be
responsible for repairing Village owned irrigation systems on any Village owned property.
19. It is the contractor's responsibility for private and public utility locates before excavation. Call JULIE at 811.
20. All construction within state or county right-of-way requires a permit from that agency.
21.
If for any reason the above conditions, Village Code, other applicable standards and/or the approved drawings are not complied with, the
Contractor will be notified and site construction will cease. Further non-compliance may result in fines to the Contractor.
Page 3 of 3
Revised 5/10/2019 by LR
FOR OFFICE USE ONLY
Location (to & from):Site Street:
Items on File
Surety:
Surety Check No.:
Surety Issued By:
Traffic Control Plan
Emergency Contingency Plan
Insurance
Plans Attached
Specifications Attached
Permits Required
County Permit #
State Permit #
Approved by:
Date
Permit Fee
Infrastructure Maint. Fee
PERMIT DENIED (see attached comments)
Date Issued:
Floodplain Permit not Required Floodplain Permit Required
ACKNOWLEDGEMENT & SIGNATURE
I agree, to the best of my knowledge and belief, that the information stated in this application and in all supporting plans and documents is true and accurate. In addition, to
the best of my knowledge and belief, the proposed collocation of the small wireless facility sought by this application complies with the written design standards
established by the Village, and with the various other requirements set forth in the Small Wireless Facilities Deployment Act (P.A. 100-585), of the Village Code, and other
applicable provisions of the Village Code.
This is an application only. Completion of this application does NOT entitle the applicant to commence construction. I, the applicant, agree to conform to all applicable laws
of the Village. I also agree that all work performed will be in accordance with the plans and specifications as set forth in the approved permit. I understand that the approval
of this application and issuance of a permit does not obviate the need to comply with all applicable laws and ordinances. I agree to hold harmless and indemnify the Village
for any claim against the Village as the result of any act of commission or omission by or on behalf of the undersigned, his/her agent, principle, contractor, subcontractor or
supplier. I, the undersigned, am the duly authorized and contracted representative of the applying entity/owner of the small wireless facility.
Printed Name of Applicant Title of Applicant
Applicant's E-Signature
By typing your name you agree to the terms and conditions of this permit.
Date
PERMIT FEE SCHEDULE
Installation Type
Fee Quantity
Request to collocate a small wireless facility that includes the installation of a new utility pole
$1,000.00
Request to collocate a single small wireless facility on an existing utility pole or wireless support
structure
$650.00
Request to collocate multiple small wireless facilities on existing utility poles or wireless support
structures addressed in a single application
$350.00 per small
wireless facility
To Planning for review:
Planning approval received
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Village of Wheeling Small Wireless Facilities Permit PERMIT (Village of Wheeling)

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Completed 17 July 2020

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