Application for access to and ongoing use of public ways by telecommunications providers

TELECOMMUNICATIONS PROVIDERS

_______________________________________________

Name of local unit of government

1. 
   GENERAL INFORMATION:
   
   
   

1.2 Applicant’s legal name:______________________________________

Mailing Address:___________________________________________

___________________________________________

____________________________________________
Telephone Number:_________________________________________

Fax Number: ______________________________________________

Corporate website: __________________________________________

Name and title of Applicant’s local manager (and if different) contact person regarding this application:

_________________________________________________________

Mailing Address:___________________________________________

___________________________________________

___________________________________________

Telephone Number:_________________________________________

Fax Number: ______________________________________________

E-mail Address:

1.3 Type of Entity: (Check one of the following)

_____ General Partnership

_____ Limited Partnership

_____ Limited Liability Company

_____ Individual

_____ Other, please describe: _____________________________________

1.5 Description of Entity:

1.5.1Jurisdiction of incorporation/formation;

1.5.2Date of incorporation/formation;

1.5.3If a subsidiary, name of ultimate parent company;

1.5.4Chairperson, President/CEO, Secretary and Treasurer (and equivalent officials for non-corporate entities).

1.6Attach copies of Applicant’s most recent annual report (with state ID number) filed with the Michigan Department of Licensing and Regulatory Affairs and certificate of good standing with the State of Michigan. For entities in existence for less than one year and for non-corporate entities, provide equivalent information.

1.7Is Applicant aware of any present or potential conflicts of interest between Applicant and Municipality? If yes, describe: ________________________________________

_____________________________________________________________________________.

1.8 In the past three (3) years, has Applicant had a permit to install telecommunications facilities in the public right of way revoked by any Michigan municipality?

1.9In the past three (3) years, has an adverse finding been made or an adverse final action been taken by any Michigan court or administrative body against Applicant under any law or regulation related to the following:

1.9.1A felony; or

1.9.2A revocation or suspension of any authorization (including cable franchises) to provide telecommunications or video programming services?

1.10[If Applicant has been granted and currently holds a license to provide basic local exchange service, no financial information needs to be supplied.] If publicly held, provide Applicant’s most recent financial statements. If financial statements of a parent company of Applicant (or other affiliate of Applicant) are provided in lieu of those of Applicant, please explain.

1.10.1 If privately held, and if Municipality requests the information within 10 days of the date of this Application, the Applicant and the Municipality should make arrangements for the Municipality to review the financial statements.
If no financial statements are provided, please explain and provide particulars.
____________________________________________

2. 
   DESCRIPTION OF PROJECT:
   
   
   

1.12Describe in plain English how Municipality should describe to the public the telecommunications services to be provided by Applicant and the telecommunications facilities to be installed by Applicant in the Public Ways.

1.13Attach route maps showing the location (including whether overhead or underground) of Applicant’s existing and proposed facilities in the public right-of-way. To the extent known, please identify the side of the street on which the facilities will be located. (If construction approval is sought at this time, provide engineering drawings, if available, showing location and depth, if applicable, of facilities to be installed in the public right-of-way).

1.14Please provide an anticipated or actual construction schedule.

1.15Please list all organizations and entities which will have any ownership interest in the facilities proposed to be installed in the Public Ways.

1.16Who will be responsible for maintaining the facilities Applicant places in the Public Ways and how are they to be promptly contacted? If Applicant’s facilities are to be installed on or in existing facilities in the Public Ways of existing public utilities or incumbent telecommunications providers, describe the facilities to be used, and provide verification of their consent to such usage by Applicant.

3. 
   TELECOMMUNICATION PROVIDER ADMINISTRATIVE MATTERS:
   
   Please provide the following or attach an appropriate exhibit.
   
   
   

1.18Location of all records and engineering drawings, if not at local office;

1.19Names, titles, addresses, e-mail addresses and telephone numbers of contact person(s) for Applicant’s engineer or engineers and their responsibilities for the telecommunications system;

1.20Provide evidence of self-insurance or a certificate of insurance showing Applicant’s insurance coverage, carrier and limits of liability for the following:

1.20.1Worker’s compensation;

1.20.2Commercial general liability, including at least:

1.20.2.1Combined overall limits;

1.20.2.2Combined single limit for each occurrence of bodily injury;

1.20.2.3Personal injury;

1.20.2.4Property damage;

1.20.2.5Blanket contractual liability for written contracts, products, and completed operations;

1.20.2.6Independent contractor liability;

1.20.2.7For any non-aerial installations, coverage for property damage from perils of explosives, collapse, or damage to underground utilities (known as XCU coverage);

1.20.2.8Environmental contamination;

1.20.3Automobile liability covering all owned, hired, and non-owned vehicles used by Applicant, its employee, or agents.

1.21Names of all anticipated contractors and subcontractors involved in the construction, maintenance and operation of Applicant’s facilities in the Public Ways.

4. 
   CERTIFICATION:
   

Date Type or Print Name: ________________

Title