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Eligible Facility Request - Verizon - 2018 General Project Description: Replace \7~ antennas ~_______ . _. ~_ _ _. _ _ _ . _.a_ _._. __ .~ ._.._ _ ~ ._._~_______._.~ APPLICANT INFORMATION `5 ~$` ~~ Name:. Signature (see acknowledgements): ((~~ ~ Address: ~ ~G ~ ~~C`k.~~~J S `'~~-2'C ~~ '~ ~~°~S"fit-F,',~ Phone: ( ~~ )~ J~ l ~ "7 0 City: PROPERTY OWNER INFORMATION• ___ N ~ .o_.___._~_~.__ ___ _. _ /~~~ ~---7_...~.__. __._ Crown Castle Name: Signature (see acknowledgementsf 4301 Hacienda Drive, Suite 410 Pleasanton CA 94588 Address: 925 737 1097 Phone: ( ) - State/Zip: PROJECT INTAKE (City Use Only) File No: ~~~~~~ ~ "~ APN: ~~- - ~ - ~j~ Zoning: ~- ~ € GP: ` ~ ~ ~I~ n~ Checked in by: ~~_~. ~~~~~ S~ Email: G~Gi.v.~~+~_~S'~~ C~f~-W~+tcs(lr,tc State/Zip: dan i el. pierce@crowncastle.com Mobile: ( ) - Email: ACKNOWLEDGEMENTS !' "_ ____ ___._ _._______.~_ ~,_ _ __.._ ~_._y___v__ ~_ .~_ __._._~_~_ _~ Submittal of this development application and signature by the Applicant and Property Owner constitutes acknowledgment of the following by all parties: (1) That the information submitted with this application is true and accurate to the best of my knowledge. and belief. I understand that the City is not responsible for inaccuracies in information presented, and that inaccuracies may invalidate any approval or clearance granted; (2) The Project Site is not included on the Hazardous Wastes and Substances Sites List pursuant to Cal. Gov. Code § 65962.5; (3) A vested right to a land use entitlement or building permit will not be conferred without additional approval by the West Valley Sanitation District; and (4) The City of Campbell is granted release to copy and reproduce electronically, in whole or.in part, drawings and all other materials submitted with this development application for the City's regulatory, administrative, and legal functions, including sharing of information with other governmental entities and for compliance with the California Public Records Act (CPRA); (5) It is understood that the application is submitted'at risk', and that application materials may be required to be modified, and if denied, shall not be reimbursed application -fees. If any of these statements cannot be affirmatively acknowledged, please inform the planner before submitting a development application. Eligible Facility bequest Application Form 910 McGlincey Lane, Campbell, CA 95008 Assessor's Parcel Number: 412 34 019 oF.~`t'yo . ~~ ''',`" -~`A~r 814277 app;292961 VzW u ~ "t ,~ `~- ~. ,~ ~~a - - a r... ~..~-~ i - ' Ok CN AA~ - - CITY of CAMPBELL . Community Development Department Eligible Facility Request Application . Applications for a wireless communications facility must be made in person by someone with authority to' act on behalf of the applicant during the planning division public- counter hours. Applications and any subsequent resubmittal that are not made in person by someone with authority to act on behalf of the applicant and during scheduled times shall not be accepted for filing and will be returned. The staff planner who is on duty when your application is submitted will give the application a cursory review for completeness. If any of the following items are not provided, in full, the application will not be accepted. Further, please be advised that the submission of materials and information, including when responding to a notice of incompleteness, must be given to the City in -one (1) submittal packet. IJ '' Application. A fully completed and executed City application form, including Supplemental Forms A, B, 2. Application filing fees. Application fees, in a payment format accepted by the Cit finance de artment ® Y p , as maybe amended from time to time.. a. Planning Division Fees: $57.00 Zoning Clearance Fee (FY18) ki: Building Division Fees: Due to the "complexity of permit fees for new construction, it is required `- that you visit the Building Inspection & Safety Counter to determine the amount required for the building permit fee. 3. Written statement; Type of approval 'sought. A written narrative describing the project in detail (including a summary of facility- equipment) and explaining why the permit qualifies as an eligible facility quest. ~~ 4. City-owned. If the proposed facility is to be located on a City-owned building,- pole, or other structure, the application must be signed by an authorized representative of the City and accompanied by the license or '"other agreement authorizing applicant's use of such City-owned property. i5. dependent consultant deposit. A fee deposit, if required, to reimburse the City for its costs to retain an independent consultant to review the technical aspects of the application. - - - -6. Site and construction plans. Complete -and' accurate plans, drawn to scale, signed, and sealed .by a- - - California-licensed engineer, land surveyor, and/or architect, which include, at a minimum; the following: a. :Number of Plan- Sets: i. Seven (7) full-size sets (24" x 36") Must FOLD to 8 1/2" X 11" size. 1. At least two much be "wet-signed" and stamped by a State of California licensed architect or engineer). ii. Two (2) "wet-signed" reduced sets (11" x 17") iii. One (1) Digital Copy of plans and associated materials on USB / CD 1. PDF Format in 24" x 36" scale / 300 dpi and 11" x 17" scale /300 dpi b. Minimum Details to Include on Plan Drawings: i._ A site plan and elevation drawings for the facility as existing and. as proposed with all height and width measurements explicitly stated. ii. A depiction, with height and width measurements explicitly stated, of all existing and proposed transmission equipment. . iii. A depiction of all existing, and proposed utility runs and points of contact. - - _iv: A depiction of the leased or licensed. area of the site with_all. rights-of--way and easements - for access and utilities labeled in plan view and including legal boundaries of the leased, licensed or owned. area surrounding the proposed facility and any associated access or utility easements. Eligible Facility Request Application -Submittal Requirements Overview Page 2 of 2 v. A demolition plan (if applicable). 7. Prior permits. True and correct copies of all previously issued permits, including, without limitation, all required conditions of approval. For eligible facilities requests, the application must also include a certification by the applicant that the proposal will not violate any previous permit or conditions of approval why any violated permit or conditions does not prevent approval under Section 6409(a) and the FCC's regulations implementing this federal law. 8. FCC compliance; Affirmation of radio frequency standards compliance. An affirmation, under penalty of perjury, that the proposed installation will be FCC compliant and will not cause members of the general public to be exposed to RF levels that exceed the MPE levels deemed safe by the FCC. The application shall include an RF report (or other documentation) acceptable to the City, evidencing that the proposed facility, as well as any collocated facilities, and cumulative conditions will comply with applicable FCC standards and regulations, (including, but not limited to, federal RF exposure standards and exposure limits). Documentation of FCC compliance shall be required for all wireless communications facility permits, including, without limitation, permit modifications. 9. Required Licenses or Approvals. Evidence that the applicant has all current licenses and registrations from the FCC, the CPUC, and any other applicable regulatory bodies where such license(s) or ~stration(s) are necessary to provide wireless communication services utilizing the proposed wireless communication facility. 10. Structural analysis. A structural analysis, prepared, signed, and sealed by aCalifornia-licensed engineer that assesses whether the proposed wireless communications facility complies with all applicable building codes. '~' a. Four (4) sets in 8%" x 11"format and "wet-signed". 11. Other permits. An application for an eligible facility request shall include all permit applications with all required application materials for each and every separate permit required by the City including, but not limited to, a building permit (see Attachment A) and an encroachment permit (if applicable). ~l - Jx~ 12. Other information. Such other information as the City may require, as specified in publically available ~"~ materials, including, but not limited to, information required as stated on the City's website.