Site Address: _______________________________________________ Long Beach, CA 908 ___
Agent Name: __________________________________________ Ph: _______________________
Agent Company: _______________________________________ Fax: ______________________
Mailing Address: __________________________________________________________________
City: ____________________________ State: _____ ZIP: ______ Email: ____________________
Agent Signature: __________________________________ Title: ___________________________
Wireless Carrier Name: ________________________ Corporate Rep.: ________________________
Mailing Address: __________________________________________________________________
City: ____________________________ State: _____ ZIP: ______ Ph: ______________________
Please submit the following items with this application:
Current color photos of the site, showing at least 3 views, taken by applicant in the last 30 days. Include
color prints on 8 ½ × 11-inch paper, and digital copies of each in jpeg format.
Copy of the original Notice of Final Action and Conditions of Approval for the permit (CUP or SPR) for
which you are applying for a 10-Year Review, and any subsequently-approved permits. Include digital
copies of each in pdf format.
Letter of Authorization from Carrier to Agent to obtain 10-Year Review/Renewal, both on paper and a
digital copy in pdf format.
APPLICATION AND COMPLIANCE STATEMENT
(I/We), the undersigned, declare under penalty of perjury under the laws of the State of California that (I am/We are) the
operator, or the authorized representative of the operator, of the wireless telecommunications facility involved in this
application; that the information on this application and attached hereto and all the statements and answers contained herein
are in all respects true and correct.
(I/We) further certify that this wireless telecommunications facility is, at the date of this application, operating in compliance
with applicable provisions of the Zoning Ordinance (Title 21, Long Beach Municipal Code), with all conditions of approval of
all effective and applicable Planning permits issued by the City of Long Beach for this facility, and with all laws, rules, and
regulations of the State of California and the United States applying to the operation of this facility.
Signed: _____________________________ Name and Title: ______________________________________
Date: ____________ Authorized Agent For: ___________________________________________________
BELOW THIS LINE FOR STAFF USE ONLY
Filing Date: _______________
Project No.: _______________
Received by: _____________
Council District: ____________
Assigned Planner: __________
10-Year Review No: _______________
Original Case No.: ________________
Related Case Nos.: _______________
_______________________________
Related Addresses: _______________
_______________________________
Approval: ______________ on: _______________ .
Planner Date
Due date of next 10-year renewal: _______________ .
Date
Note: 10-year renewal dates are calculated from the
date of initial entitlement of the facility. Overdue
renewals will be due again in less than 10 years.
Wireless Telecommunications Facility
10-Year Review/Renewal Application
Development Services
Planning Bureau
411 West Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.6194
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