2023/12/13 Council Agenda Packet

Exhibit A Pole Attachment Application And Checklist Company Name ______________________________ # of New Contacts _______ # of Overlash _______ Total # of Poles _______ Note: maximum of 50 sequential poles per application. Application Fee: ($185 Base Fee & $12 per pole) ________________________ Please refer to Exhibit C for application requirement details. Type of Attachment Coax - Does the Bundle Exceed 2” Diameter? Yes No Fiber - Does the Bundle Exceed 2” Diameter? Yes No Guy Wire – Distribution Poles only Power Supply This application is submitted in accordance with Licensor’s present policies and is expressly subject to the provisions set forth in the Pole Attachment License Agreement. Applications for attachment to all District poles will required specific loading data to include diameter, weight and tension of proposed attachment. Enclose District provided map identifying Licensor’s poles to which equipment will be attached including pole numbers. If necessary, contact the Licensor for assistance in identifying pole numbers. It shall be Applicant’s responsibility to maintain proper clearances and conform to all District requirements, all requirements of the National Electric Safety Code and applicable state and local electrical codes, and all other applicable laws and regulations. If you have questions regarding this application, please contact: jointuse@snopud.com. Applicant/Licensee Signature _____________________________ Print ________________________________ Title _________________________________________________ Phone _______________________________ Email ________________________________________________ Date ________________________________ Application Reference # (16 character limit) ________________________ PO Box 1107 Everett, WA 98206 FOR INTERNAL USE ONLY Notification _______________________ WO ____________________ NJUNS ______________________ CHECKLIST  Signed and Completed Pole Attachment Application  Pole Attachment Application Fee Check  Pictures of the Pole  Overview Map  Fielding Sheet  Commscope Report __________________________ Refer to Exhibit C - Joint Use Fielding Appendix for details of the requirements.