Light Standard/Utility Pole Endorsement

For WSDOT Use Only
IC Number / Lease Number
To Be Completed By Applicant
Light Standard/ Utility Pole Number / Licensed with the FCC (Yes/No)
Franchise Number / License Number
New Facility (Yes/No) / Replacement of existing light/pole (Yes/No)
Site address / State Route Number (SR) / Mile Post Number (MP)
Section / Township / Range / Latitude / Longitude
Applicant Name / Applicant Site Number/Name
Legal entity, Legal Name of Tenant / DBA:
Mailing Address / City / State / Zip Code
Billing Address / City / State / Zip Code
Applicant E-Mail Address / Applicant Phone Number
Signature Of Applicant / Title
Type Or Print Name / Date
Additional information/Comments:
To be signed by Light Standard/Utility Pole Owner
The proposed installation/modification of the communication equipment submitted to the Light Standard/Utility Pole Owner(Owner), to belocated on the pole referenced above, has been reviewed. A review of the structural analysis calculations performed determined that the existing pole:
WILL support the increase loading; the review confirms that the structural loading for the existing pole remains within the design parameters used in the analysis. The review used the communication equipment loads provided by the Applicant in accordance with the National Electric Safety Code, applicable EIA/TIA and electrical industry standards.
WILL NOT support the increase loading and it is recommended that the existing pole beupgradedor replaced;the reviewdoes not confirm that the structural loading remains within the design parameters used in the analysis. The review used the communication equipment loads provided by the Applicant in accordance with the National Electric Safety Code, applicable EIA/TIA and electrical industry standards.
Upon approval, the proposed communication equipment installation/modification (Work) will be completed by the Owner, Owner’s contractor, agent, or employee; when completed the structural design and installation will comply with recognized national standards for the structural requirements and meet all utility codes and industry requirements. The Owner accepts all liability for damages that result from the Owner or the agents or employees of the Owner’sWork.
The State, Governor, Commission, Secretary, WSDOT, all State Agencies and all officers and employees of the State, will not be responsible in any manner for:any loss or damage that may happen as a result of the Work on the pole or any part; for any loss of material or damage to any of the materials or other things used or employed in the performance of the Work on the pole;for injury to or death of any persons, either workers or the public; or for damage to the public for any cause which might have been prevented by the Owner, or the workers, or anyone employed by the Owner, including but not limited any contractors or subcontractors performing any Work.The Owner shall be responsible for any liability imposed by law for injuries to, or the death of, any persons or damages to property resulting from any cause whatsoever during, or as a result of the performance of the Work on the pole.
Subject to the limitations of RCW 4.24.115, the Owner shall indemnify, defend, and save harmless the State, Governor, Commission, Secretary, WSDOT, all State Agencies and all officers and employees of the State from all claims, suits, or actions brought for injuries to, or death of, any persons or damages resulting from Work completed on the pole or in consequence of any negligence or breach of contract regarding the Work, or the use of any improper materials in the Work.
The Owner specifically assumes all potential liability for actions brought by employees of the Owner and, solely for the purpose of enforcing the defense and indemnification obligations set forth above, the Owner specifically waives any immunity granted under the State industrial insurance law, Title 51 RCW. This waiver has been mutually negotiated by the parties. The Owner shall similarly require that each SubOwner it retains in connection with the project comply with the terms of this paragraph, waive any immunity granted under Title 51 RCW, and assume all liability for actions brought by employees of the SubOwner.
Signature / Title
Type Or Print Name / Date

RES 425

11/2015

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