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City of Redmond, WA
Phase I Application For Location of Telecommunications Facilities on City Property
IMPORTANT: THIS APPLICATION CAN NOT BE SUBMITTED UNLESS ACCOMPANIED BY AN APPLICATION FEE OF TWO THOUSAND DOLLARS ($2,000) AS REQUIRED BY CITY OF REDMOND RESOLUTION NO. 1042 AND SECTION 12.14.0500 OF THE REDMOND MUNICIPAL CODE.
General Information
Name of Applicant Telecommunications Provider or Carrier:__________________________Address:____________________________
City:_______________________________
State:______________________________
Zip Code:___________________________
Telephone:__________________________
Is this Telecommunications Provider or Carrier presently registered with the City of Redmond?___________________________
PLEASE NOTE: All cable operators, telecommunications carriers, and telecommunications providers engaged in the business of transmitting, supplying or furnishing of telecommunications service of any kind originating or terminating in the City of Redmond shall apply and obtain a Telecommunications Business Registration from the City pursuant to Chapter 5.75 of the Redmond Municipal Code.
Name of Person Filing this Application:___________________________
Title:_______________________________
Company:___________________________
Address:____________________________
City:________________________________
State:_______________________________
Zip Code:____________________________
Telephone:___________________________
Are you serving as agent for the above named telecommunications provider or carrier? If yes, please attach proof of agency.___________________________
Property and Facility Information
Location of Subject Property:_____________________________
Description of Subject Property:___________________________
Description of the Telecommunications Facilities and/or Other Equipment Proposed to be Located on Subject Property (Attach additional pages if necessary):_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Telecommunications Service to be Provided by Proposed Development:___________________________
PLEASE NOTE: The provision of cable service, video dialtone service or other video programming service may be subject to cable franchising by the City of Redmond.
Certification
I certify that the information and any attachments herewith submitted are true and correct to the best of my knowledge and that I have the authority to file this application and act on behalf of the above named telecommunications provider or carrier.
Signature:___________________________________
Please Print Name:___________________________
Date:_______________________________________
SUBMIT THIS APPLICATION TO THE CITY OF REDMOND'S EXECUTIVE OFFICE. LOCATED ON THE THIRD FLOOR OF THE CITY OF REDMOND'S CITY HALL, 15670 N.E. 85TH STREET, REDMOND, WA 98073 - 9710. PLEASE CONTACT THE EXECUTIVE OFFICE AT 556 - 2101 WITH ANY QUESTIONS REGARDING THIS APPLICATION
Received By:_____________________________
Signature:_______________________________
Please Print Name:________________________
Date:____________________________________