Applicant (wireless company name)

Utility pole location (utility pole number and street address)

Utility pole owner

Name of street the utility pole is actually on

Priority number of the street in which the utility pole is located [See wireless Street Priority Map dated May 12, 2009, located at http://www.portlandonline.com/cable/index.cfm?c=46289]

1. Street Use Priority Acknowledgement. Applicant acknowledges that the City has ranked all of Portland’s Streets in order of priority for placing wireless facilities on utility poles. Use utility poles for wireless facilities on:

a. Priority 1 streets (generally freeways, highways and streets in industrial areas), before using poles on;

b. Priority 2 streets (generally high traffic volume streets), before using poles on;

c. Priority 3 streets (generally medium traffic volume streets or one way streets), before using poles on;

d. Priority 4 streets (generally low volume traffic streets in residential areas).

As indicated (above) Applicant will locate facilities on Priority __________.

(Note to Applicant: If located on Priority 4, you must also submit a check in the sum of $2,000 to the Office of Cable Communications and Franchise Management, and answer questions 7- 13.)

Staff Use Only: If Priority 4, confirm questions 7- 13 answered below and that the check is attached, or write N/A if not Priority 4.

2. Tallest Pole co-location preference. Applicant acknowledges that the City’s Right-of-Way Agreement with each wireless company requires wireless facilities to be placed on the tallest pole available. If any taller poles (e.g., high voltage transmission line poles), including “skipped poles,” were rejected in favor of a shorter pole (e.g., a low voltage distribution, communication, or guy pole), explain why those taller poles were rejected.

Staff Use Only: Confirm tallest pole available used or explanation attached.

3. Does applicant intend to replace the pole?

4. Street tree requirement. If the pole will be replaced, provide a check in the sum of One Thousand Dollars ($1,000) to either plant a street tree adjacent the pole, or for deposit into the Park Bureau’s Tree Damage Fund. If a street tree is not allowed, attach a copy of the denial.

Staff Use Only: Confirm check and/or the denial is attached.

5. Replacement pole width limitation & authorization. If Applicant plans to replace the utility pole, a copy of a written statement from the pole owner must be attached to this application stating that the narrowest pole will be used as required by the Oregon Public Utility Commission.

Staff Use Only: Confirm letter attached if pole replaced or write N/A.

6. Magnitude limitation on replacement utility poles. Applicant acknowledges that the City’s Right-of-Way Agreement limits the combined height of replacement utility poles and mounting devices. If Applicant plans to replace the utility pole:

•  What is the height of the existing utility pole as measured above ground level? ______

•  What is the height of the proposed utility pole as measured above ground level? ______

Staff Use Only: Confirm within height limits or write N/A.

7. Limitation on Antennas above top of pole. Applicant acknowledges that the City’s Right-of-Way Agreement limits the height antennas are allowed to project above the top of the pole. If antennas will be placed above the top of the pole, what will the height be from the top of the pole to the top of the antennas?

Staff Use Only: Confirm within limits or write N/A.

8. Required conformance to color and surface of original pole. Applicant acknowledges that the City’s Right-of-Way Agreement requires conformance where possible to the color and surface of the existing or original pole prior to installation. Describe how the facilities and the replacement pole (if applicable) will be painted, coated, or given some form of surface application that will conform to the color and surface of the existing or original pole, and confirm that this treatment will occur before installation and will be maintained afterward.

Staff Use Only: Confirm meets requirements.

Co-location requirement. Applicant acknowledges that the City’s Right-of-Way Agreement expresses the City’s goal that wireless facilities in residential or commercial areas be co-located on existing structures such as buildings, water towers, or cell towers before they are sited on utility poles in the streets. Only answer the following if the wireless facilities will be placed on an existing or replacement utility pole in a Priority 4 (residential) street.

9. RF Contour maps required. Provide RF contour maps (in color) illustrating the calculated coverage using the proposed antennas at the target signal level, plus and minus 5 dB, and the calculated coverage areas for all existing adjacent cell sites, to support the rejection of other structures. If other structures were ruled out for non-RF coverage reasons, identify and explain those reasons.

Staff Use Only: Confirm maps attached, and rationale for rejection of other structures, where applicable or write N/A.

10. Limitation on equipment dimensions. The total of the height plus width plus depth of any equipment cabinet that will be mounted on the pole is no more than 120 lineal inches combined [(h + w + d) ≤ 120”]. Provide the dimensions of the equipment:_________________________

Staff Use Only: Confirm equipment is within maximum limits or write N/A.

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11. Attach a photograph of the pole as it exists before being replaced. Also attach a photo simulation of the pole and attached equipment as proposed after replacement, including all antennas, equipment, conduit, meters, etc. The photo simulation must be from the same perspective (distance, height, and angle) as the original photo.

Staff Use Only: Confirm photos are attached or write N/A.

12. Notice to residents and property owners, and public meeting, required. Applicant acknowledges that the City’s Right-of-Way Agreement requires notice to affected neighbors, including residents and property owners, in the case of replacement structures on residential (Priority 4) streets. Did Applicant conduct or participate in a meeting at least 30 days ago? Did Applicant provide notice of the meeting 14-30 days in advance, and was it sent to: property owners and occupants within a 400 foot radius of the pole; the neighborhood association; the business association; the pole owner; and the City? The photo and photo simulation required in question 11, above, must be available at the public meeting.

Yes No:

If yes, on what date: ______________________

Attach a copy of meeting notice.

Staff Use Only: Confirm meeting held or write N/A.

13. Response to public. Did Applicant modify its proposal because of community feedback? If so, how (attach additional pages if necessary)?

Staff Use Only: Confirm modification, or write N/A.