MCI-CS190222T H E - C k T Y - O F
COPPELL
i
PUBLIC RIGHTS-OF-WAY MANAGEMENT ORDINANCE
REGISTRATION FORM
Submit completed form to the Engineering Dept., Town Center, 265 Parkway Blvd., CoppeIl, TX, 75019
This registration form is required by Sec. 6-14-3 of the City of Coppell Code of Municipal Ordinances It is
to be renewed every other year by March 1. This document does not take the place of obtaining a Right -Of -
Way Use Permit prior to performing any work in the public right-of-way.
1. Date of Submittal: 02 1 15 / 2019
2. Name and Address of Service Provider (Include all names used within the last S years):
One Verizon Way, Basking Ride New Jersey 07290
MClmetro Access Transmission Services LLC
3. Is Provider certified by the Texas Public Utility Commission?
( ) NO pQ YES if YES, Certificate Number 50004
4.
Does Provider have a Valid License or Franchise Agreement with the City of Coppell?
()0 NO ( ) YES
if YES, Ordinance Number.
Date Approved I I
5. Provide Two Business Contacts (One must be within the Dallas/Fort Worth area):
Bill Kiraly James Wallace III
Name Name
Engr IV Spec - Network Engineering & Operations Engr III Spec - Network Engineering & Operations
Title Title
400 International Parkway, Richardson, TX 75081
Address
��iL��Y�tLI;•
600 Hidden Ridge E02E087, Irving, TX 75038
Address
972-444-5357
Telephone
6. Provide Two Emergency Contacts (Must be available AI ALL TIMES):
24 Hour Network Operations Center
Name
Title
Address
Bill Kiraly
Name
_Enar IV Spec -Network Engineering &Operations
Title
400 International Parkway, Richardson, TX 75081
Address
1-800-624-9675 214-237-7746
Telephone (No Charge to the City) Telephone (No Charge to the City)
7. Have the names, addresses, and contact information for all known contractors or subcontractors
that will be working in the public right -of --way on behalf of the Provider been furnished to the
City?
{� YES () NO if ND, Reason:
S. Has proof of insurance meeting the requirements of Sec. 6-14-3 B.4(h) of the Public Rights -Of -
Way Management Ordinance been furnished to the City (the City must be named as an additional
insured on the policy by using endorsement CG 20 26 or broader)?
Qq YES { ) NO if NO, Reason:
�1� "W�dd���� James Wallace III 02/15/2019
Signature of Applicant Printed Name Date
FOR CITY USE ONLY
(�REGISTRATION ACCEPTED
Comments:
( )REGISTRATION DENIED
Signatu a of City Representative Printed Name Date
Provider shall irtdetuu� and forever hold har►nless against the City of Coppell each acrd every claim, deutaud, or cause of
action that Wray be stade or come against rt by reason of or if arry way arising out of the closure, blocking, excavating,
cutting, twtneling, or other work by the provider under permit frons the City, if such perstit is granted.