METRO Act Permit Application Form Revised 12/06/02 _________________________________________ 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 MCLA 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/0,1607,7-159-16372_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." MCLA 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." MCLA 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, MCLA 484.3105(3).
1 GENERAL INFORMATION:
1.1 1.2 Date: _____________________________ 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:___________________________________________ ___________________________________________ 2
___________________________________________ 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 1.5
Assumed name for doing business, if any: ___________________________ Description of Entity:
1.5.1 Jurisdiction of incorporation/formation; 1.5.2 Date of incorporation/formation; 1.5.3 If a subsidiary, name of ultimate parent company; 1.5.4 Chairperson, President/CEO, Secretary and Treasurer (and equivalent officials for non-corporate entities). 1.6 Attach copies of Applicant’s most recent annual report (with state ID number) filed with the Michigan Department of Consumer and Industry Services and certificate of good standing with the State of Michigan. For entities in existence for less than one year and for noncorporate entities, provide equivalent information. 1.7 Is 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. 1.9 In 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: 1.9.1 A felony; or
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1.9.2 A 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. ____________________________________________
2 DESCRIPTION OF PROJECT:
2.1 Provide a copy of authorizations, if applicable, Applicant holds to provide telecommunications services in Municipality. If no authorizations are applicable, please explain. 2.2 Describe 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. 2.3 Attach 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). 2.4 Please provide an anticipated or actual construction schedule.
2.5 Please list all organizations and entities which will have any ownership interest in the facilities proposed to be installed in the Public Ways. 2.6 Who 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 4
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. 3.1 3.2 Address of Applicant’s nearest local office; Location of all records and engineering drawings, if not at local office;
3.3 Names, 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; 3.4 Provide evidence of self-insurance or a certificate of insurance showing Applicant’s insurance coverage, carrier and limits of liability for the following: 3.4.1 3.4.2 Worker’s compensation; Commercial general liability, including at least: 3.4.2.1 3.4.2.2 3.4.2.3 3.4.2.4 Combined overall limits; Combined single limit for each occurrence of bodily injury; Personal injury; Property damage;
3.4.2.5 Blanket contractual liability for written contracts, products, and completed operations; 3.4.2.6 Independent contractor liability;
3.4.2.7 For any non-aerial installations, coverage for property damage from perils of explosives, collapse, or damage to underground utilities (known as XCU coverage); 3.4.2.8 Environmental contamination; 3.4.3 Automobile liability covering all owned, hired, and non-owned vehicles used by Applicant, its employee, or agents. 3.5 Names of all anticipated contractors and subcontractors involved in the construction, maintenance and operation of Applicant’s facilities in the Public Ways. 5
4 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”) _________________________________ _______________________ Date By:______________________________ Type or Print Name: ________________ _________________________________ Title
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