INSITE CUSTOMER APPLICATION (BROADBAND) PAGE 1.PDF
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WORKSHEET 1 OF 2 (COMPLETE BOTH WORKSHEET TABS) CUSTOMER APPLICATION A Site Application Fee to be paid upon submission of this DATE SUBMITTED: Customer Application. CUSTOMER INFORMATION COMPANY NAME: MARICOPA COUNTY PHONE: 602-506-1067 ENTITY Type: i.e. Inc., LLP POLITICAL SUBDIVISION FAX: STATE of Inc. Arizona SERVICE (PCS, SMR): CUSTOMER ADDRESSES COMPANY Address: 2801 WEST DURANGO STREET CITY/STATE: PHOENIX, AZ ZIP : 85009 BILLING Address: 3324 WEST GIBSON LANE CITY/STATE: PHOENIX, AZ ZIP : 85009 NOTICE Address 1: CITY/STATE: ZIP : NOTICE Address 2: CITY/STATE: ZIP : CUSTOMER CONTACTS PRIMARY CONTACT: TOM CROSBY PHONE: 602-506-5264 TITLE: DIRECTOR OF WIRELESS E-MAIL Address: tomcrosby@mail.maricopa.gov SIGNATORY NAME: TOM CROSBY PHONE: 602-506-5264 TITLE: DIRECTOR OF WIRELESS E-MAIL Address: tomcrosby@mail.maricopa.gov EMERGENCY CONTACT: TOM CROSBY PHONE: 602-506-1191 TITLE: DIRECTOR OF WIRELESS E-MAIL Address: tomcrosby@mail.maricopa.gov TECHNICAL/OPS: ALBERT DAIGRE PHONE: 602-506-1193 TITLE: SENIOR IT MANAGER E-MAIL Address: AlbertDaigre@mail.maricopa.gov RF ENGINEER: PHONE: TITLE: E-MAIL Address: BILLING CONTACT: TOM CROSBY PHONE: 602-506-5264 TITLE: DIRECTOR OF WIRELESS E-MAIL Address: tomcrosby@mail.maricopa.gov LEGAL CONTACT: PHONE: TITLE: E-MAIL Address: SITE INFORMATION CUSTOMER Site Name/ #: Crestview Site INSITE Name/ Site #: Site AZ 928 Fountain Hills SITE LATITUDE: 33 35 16.84n SITE LONGITUDE: 111 45 40,86 SITE ADDRESS: 11138 n. 148th Street, Fountain Hills, AZ CITY: Fountain Hills STATE: Arizona ZIP: 85268 STRUCTURE TYPE: 130' Self Support USE THIS SECTION TO PROVIDE A DESCRIPTION OF COLOCATION OR MODIFICATION REQUEST Maricopa County proposed to utilize the existing self support tower for placement of two (2) Transmit antennas and one (1) receive Antenna, one TTA, two 6' point to point dishes. Installation of new 12 x 20 equipment shelter, 45kw propane generator and one (1) one thousand gallon propane tank USE THIS SECTION TO LIST EQUIPMENT TO BE REMOVED APPLICATION PREPARED BY NAME: Trey Hutchinson PHONE: 480-383-9684 COMPANY: Motorola Solutions ADDRESS: TITLE: Construction Manager E-MAIL Address: trey.hutchinson@motorolasolutions.com