Small Cell Permit Application - Washtenaw County Road Commission

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Date of Application*
MM slash DD slash YYYY
Applicant/Property Owner*
First Last
Applicant/Property Owner Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Applicant/Property Owner Phone*
Applicant/Property Owner Email*
Contractor Name
Contractor Billing Address
Street Address Address Line 2 City State ZIP Code
Contractor Email
Contractor Phone
Site Location*
Please include the two nearest cross streets*
Township*
Side of Road
Plan/Work Order Number
Poles, New
- Yes
- No
Poles by Others, New
- Yes
- No
Number of New Poles
Colocation Utility Poles
- Yes
- No
Number of Colocation Utility Poles
Is small cell wireless facility located within 50 feet of traffic signal?
- Yes
- No
Work Description*
Hidden
Work Description*
Additional Information
File upload
Drop files here or

Max. file size: 50 MB.