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


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METRO Act Permit Application Form

Revised April 6, 2012
_________________________________________

Name of Local Unit of Government
APPLICATION FOR

ACCESS TO AND ONGOING USE OF PUBLIC WAYS BY

TELECOMMUNICATIONS PROVIDERS


UNDER

METROPOLITAN EXTENSION TELECOMMUNICATIONS

RIGHTS-OF-WAY OVERSIGHT ACT

2002 PA 48

MCL SECTIONS 484.3101 TO 484.3120
BY
[Name of Company]

(“APPLICANT”)
Unfamiliar with METRO Act?--Assistance: Municipalities unfamiliar with Michigan Metropolitan Extension Telecommunications Rights-of-Way Oversight Act (“METRO Act”) permits for telecommunications providers should seek assistance, such as by contacting the Telecommunications Division of the Michigan Public Service Commission at 517-241-6200 or via its web site at http://www.michigan.gov/mpsc/0,4639,7-159-16372_22707---,00.html.
45 Days to Act—Fines for Failure to Act: The METRO Act states that “A municipality shall approve or deny access under this section within 45 days from the date a provider files an application for a permit for access to a public right-of-way." MCL 484.3115(3). The Michigan Public Service Commission can impose fines of up to $40,000 per day for violations of the METRO Act. It has imposed fines under the Michigan Telecommunications Act where it found providers or municipalities violated the statute.
Where to File: Applicants should file copies as follows [municipalities should adapt as appropriate—unless otherwise specified service should be as follows]:
-- Three (3) copies (one of which shall be marked and designated as the master copy) with the Clerk at [insert address].

_______________________________________________



________________________________________

Name of local unit of government



APPLICATION FOR

ACCESS TO AND ONGOING USE OF PUBLIC WAYS BY

TELECOMMUNICATIONS PROVIDERS
By

[Name of Company]

(“APPLICANT”)

This is an application pursuant to Sections 5 and 6 of the Metropolitan Extension Telecommunications Rights-of-Way Oversight Act, 2002 PA 48 (the "METRO Act") for access to and ongoing usage of the public right-of-way, including public roadways, highways, streets, alleys, easements, and waterways (“Public Ways”) in the Municipality for a telecommunications system. The METRO Act states that “A municipality shall approve or deny access under this section within 45 days from the date a provider files an application for a permit for access to a public right-of-way." MCL 484.3115(3).
This application must be accompanied by a one-time application fee of $500, unless the applicant is exempt from this requirement under Section 5(3) of the METRO Act, MCL 484.3105(3).


  1. GENERAL INFORMATION:



1.1Date: _____________________________

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)


_____ Corporation

_____ General Partnership

_____ Limited Partnership

_____ Limited Liability Company

_____ Individual

_____ Other, please describe: _____________________________________


1.4 Assumed name for doing business, if any: ___________________________

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?



Circle: Yes No

If "yes," please describe the circumstances.

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?


Circle: Yes No
If "yes," please attach a full description of the parties and matters involved, including an identification of the court or administrative body and any proceedings (by dates and file numbers, if applicable), and the disposition of such proceedings.

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.
____________________________________________



  1. DESCRIPTION OF PROJECT:



1.11Provide a copy of authorizations, if applicable, Applicant holds to provide telecommunications services in Municipality. If no authorizations are applicable, please explain.

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.



  1. TELECOMMUNICATION PROVIDER ADMINISTRATIVE MATTERS:

    Please provide the following or attach an appropriate exhibit.



1.17Address of Applicant’s nearest local office;

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.





  1. CERTIFICATION:


All the statements made in the application and attached exhibits are true and correct to the best of my knowledge and belief.


NAME OF ENTITY (“APPLICANT”)
_________________________________
_______________________ By:______________________________

Date Type or Print Name: ________________


_________________________________

Title



S:\metroapplicationform.doc






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