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4 <br /> PLEASE READ CAREFULLY BEFORE SIGNING <br /> The undersigned agrees and acknowledges that in addition to the Antenna Site Application Fee, <br /> the applicant is responsible for all costs associated with the applicant's proposed system that is to <br /> be installed on City property, whether or not the application results in a lease. <br /> Costs may include, but are not limited to the following: <br /> 1. Interference analysis and inter-modulation study by the Engineering/Communications <br /> Consultant of the City. <br /> 2. Review of construction plans by the Engineering/Communications Consultant of the City. <br /> 3. Review of lease agreement by the City's Attorney. <br /> 4. tnspection time by the Engineering/Communications Consultant of the City. <br /> 5. Site Coordination of any items (examples: antennas or utilities) performed by the City or <br /> its Engineering/Communications Consultant. <br /> 6. Surveying, if required. <br /> 7. Utility Service by local utilities to bring or upgrade electrical or telephone service to the <br /> property for the use by the applicant. <br /> 8. All required permitting and licensing fees. <br /> A certified check in the amount of$10,000 will be required at the time of submittal of the <br /> installation plans. These escrow funds will be utilized by the landlord to pay expenses related to <br /> professional services necessary for the review of the installation plans and construction (Items 1- <br /> 6 of the list above) by the Engineering/Communications Consultant of the City. Unused escrow <br /> funds will be returned to tenant at the completion of the antenna installation. <br /> A certified check in the amount of$467.54 will be required at the time a completed application <br /> form is submitted for a City Construction Permit. <br /> Signature: . � Date: �^ � ` � <br /> (Authorized signature from wireless carrier/ lessee) <br /> Name: SG�I V(����() Title: � � �C�iulSi'�r?r� �Cl�ti �/S� <br /> —v <br /> Telephone Number: � ) � ��D �O��e-mail address: v�/�1i1 C�S �_�f�, (c�.-�� <br /> � <br /> Provide a letter of authorization, if you are representing the wireless carrier/lessee in this process. <br /> 172909v1 <br /> $ Of$ <br />