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PFI2020-00263 pF-I 1v2-O02-U N 11111 Y � City of Tigard RIGHT-OF-WAY LICENSE APPLICATION Pursuant to Chapter 15.06.070 of the Tigard Municipal Code, all person engaging in any activity within or using the City of Tigard's rights-of-way must first apply and be approved for a right-of-way license. Submit the following information and applicable fee to: City of Tigard, Attn: ROW Licenses, 13125 SW Hall Blvd., Tigard, OR 97223. Application fee of$300.00 1. Name of Entity proposed to provide services (licensee/applicant). ACN Communication Services, LLC 2. Tax ID of Entity. 38-3483729 3. Physical address and website. 1000 Progress Place Concord NC 28025 4. City of Tigard business license number or application date. 02 86 5. Authorized contact information (name, email, address, phone, etc). Mark Lammed mark©csilongwood.com 242 Rangeline Rd Longwood, FL 32750 407 260 1011 6. Description of proposed activities or services (e.g. VoIP, Internet, Cable, Voice, Infrastructure Provider, Reseller (if reseller indicate whose service is being resold)). Voip 7. Does Applicant plan to install facilities or own any facilities currently located in Tigard? If, so provide map pursuant to TMC 15.06.090(G). Does Applicant have or plan to have facilities installed underground, aerial or both? No 8. Date services started or date of first ROW usage. 4/1/2020 9. List any other municipalities in Oregon for which Applicant has an existing agreement for the provision of service(s). Eugene, OR Gladstone, OR Milwuakie, OR 10. Has the Applicant or any affiliate been found in violation by a regulatory authority? If so, identify the judicial or administrative proceeding, giving the date, name of tribunal, and result or disposition of proceeding. No Revised 7-2020 II E .'�z,r ' City of Tigard RIGHT-OF-WAY LICENSE APPLICATION 11. Attach the following documentation: a. Valid certificate from the Oregon Public Utility Commission, if applicable. b. Management/organizational chart, showing the management structure including name and unique contact information (physical address, email, direct phone, etc). c. Chart or description showing the relationship to all general partners, parent corporation, subsidiaries, affiliates and all other subsidiaries of the parent corporations, include a brief description of each entity's relationship. d. Detailed map of the City's rights-of-way which applicant intends to use, also listing the exact linear feet or dimensions of the proposed facilities that will occupy the right-of-way. If Applicant is using a third parties' facilities, indicate the owner(s) of the facilities to be used. I hereby certify, on behalf of Applicant, that to the best of my knowledge and belief this information is true and correct as of the date hereof. Licensee agrees to comply with the provisions in the Tigard Municipal Code, including, but not limited to Chapter 15.06. By executing this application, the undersigned affirms that she/he is an authorized representative of the Applicant with the authority to execute the ROW license application and bind applicant to all provisions of the Tigard Municipal Code. /I i///10# 0 Mark Lammert 7/21/20 Signature & Printed Name Title Date After reviewing the application, the City or its designee may grant the license, deny the application, or find the application incomplete and require additional information or clarification. For additional information, please contact ROW Consultants LLC at 503.724.0766 or Reba@ROWManagers.com Revised 7-2020