Type of Jacket. Enter the type of material of the outer jacket or sheath (polyethylene, PVC, lead, etc.) Form D-4 Exhibit I Page 15 of 17 ----------------------------------- ----------------------------------- LICENSEE DATE ----------------------------------- ----------------------------------- BELLSOUTH LICENSE AGREEMENT NO. LICENSOR REFERENCE NUMBER (IDEAL) ----------------------------------- ----------------------------------- CONDUIT OCCUPANCY APPLICATION NO. DATE INPUT INTO IDEAL ----------------------------------- ----------------------------------- AREA EQUIPMENT HOUSINGS TO BE PLACED IN MANHOLES ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------ Manhole Location Type Height Width Depth Weight ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------ 1 ------------ ------------ ------------ ------------ ------------ ------------ 2 ------------ ------------ ------------ ------------ ------------ ------------ 3 ------------ ------------ ------------ ------------ ------------ ------------ 4 ------------ ------------ ------------ ------------ ------------ ------------ 5 ------------ ------------ ------------ ------------ ------------ ------------ 6 ------------ ------------ ------------ ------------ ------------ ------------ 7 ------------ ------------ ------------ ------------ ------------ ------------ 8 ------------ ------------ ------------ ------------ ------------ ------------ 9 ------------ ------------ ------------ ------------ ------------ ------------ 10 ------------ ------------ ------------ ------------ ------------ ------------ 11 ------------ ------------ ------------ ------------ ------------ ------------ 12 ------------ ------------ ------------ ------------ ------------ ------------ 13 ------------ ------------ ------------ ------------ ------------ ------------ 14 ------------ ------------ ------------ ------------ ------------ ------------ Form E Exhibit I Page 16 of 17 ----------------------------------- ----------------------------------- LICENSEE DATE ----------------------------------- ----------------------------------- LICENSEE REFERENCE NUMBER LICENSOR REFERENCE NUMBER (IDEAL) ----------------------------------- ----------------------------------- AREA DATE INPUT INTO IDEAL NOTIFICATION OF SURRENDER OR MODIFICATION OF POLE ATTACHMENT LICENSE BY LICENSEE In accordance with the terms and conditions of the License Agreement between us (BELLSOUTH LICENSE AGREEMENT NO. _______________), dated _______________, 19__, notice is hereby given that the licenses covering attachments to the following poles and/or anchors and/or utilization of anchor/▇▇▇ ▇▇▇▇▇▇ are surrendered (or modified as indicated in Licensee's prior notification to Licensor, dated _____________, 19__) effective __________________. ---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Assoc. Pole Number License Number License Date Surrender or Modification Date (surrender/modified) ---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- 1 A _ A/GS ---------------------------------------------------------------------------------------------------------- 2 A _ A/GS ---------------------------------------------------------------------------------------------------------- 3 A _ A/GS ---------------------------------------------------------------------------------------------------------- 4 A _ A/GS ---------------------------------------------------------------------------------------------------------- 5 A _ A/GS ---------------------------------------------------------------------------------------------------------- 6 A _ A/GS ---------------------------------------------------------------------------------------------------------- 7 A _ A/GS ---------------------------------------------------------------------------------------------------------- 8 A _ A/GS ---------------------------------------------------------------------------------------------------------- 9 A _ A/GS ---------------------------------------------------------------------------------------------------------- 10 A _ A/GS ---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Date licensor received notification: __________________ Date licensor accepted modification: __________________ By: --------------------------------------- ---------------------------------- AUTHORIZED BELLSOUTH REPRESENTATIVE AUTHORIZED LICENSEE REPRESENTATIVE ---------------------------- Poles:_______ DISCONTINUED: Anchors: _______ ---------------------------------- Anchor/Guy Strands: _______ TITLE ---------------------------- Form F Exhibit I Page 17 of 17 ----------------------------------- ----------------------------------- LICENSEE DATE ----------------------------------- ----------------------------------- LICENSEE REFERENCE NUMBER LICENSOR REFERENCE NUMBER (IDEAL) ----------------------------------- ----------------------------------- AREA DATE INPUT INTO IDEAL NOTIFICATION OF SURRENDER OR MODIFICATION OF CONDUIT OCCUPANCY LICENSE BY LICENSEE In accordance with the terms and conditions of the License Agreement between us (BELLSOUTH LICENSE AGREEMENT NO. _______________), dated _______________, 19__, notice is hereby given that the licenses covering occupancy of the following conduit are surrendered (or modified as indicated in Licensee's prior notification to Licensor, dated _____________, 19__) effective __________________. ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- License Number License Date Surrender of Modification Date (surrender/modified) ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- 1 ----------------------------------------------------------------------------------------------- 2 ----------------------------------------------------------------------------------------------- 3 ----------------------------------------------------------------------------------------------- 4 ----------------------------------------------------------------------------------------------- 5 ----------------------------------------------------------------------------------------------- 6 ----------------------------------------------------------------------------------------------- 7 ----------------------------------------------------------------------------------------------- 8 ----------------------------------------------------------------------------------------------- 9 ----------------------------------------------------------------------------------------------- 10 ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- Date licensor received notification: __________________ Date licensor accepted modification: __________________ By: ----------------------------------- ----------------------------------- AUTHORIZED BELLSOUTH REPRESENTATIVE AUTHORIZED LICENSEE REPRESENTATIVE DISCONTINUED: Total duct footage: ----------------------------------- ------------------ TITLE NONDISCRIMINATION COMPLIANCE AGREEMENT Contractors shall comply with the applicable provisions of the following: Exec. Order No. 12138. P L. 95-507, Exec. Order No. 11246, Exec. Order No. 11625, Section 8 of the Small Business Act as amended. Railroad Revitalization and Regulatory Reform Act of 1976. Exec. Order No. 11701, Exec. Order No. 11758, Exec. Order No. 12138, Section 503 of the Rehabilitation Act of 1973 as amended by ▇▇▇▇-▇▇▇, ▇▇▇▇▇▇▇ Era Veteran's Readjustment Assistance Act of 1974 and the rules, regulations and relevant Orders of the Secretary of Labor pertaining to the Executive Orders and Statutes listed above. For contracts of or which aggregate to $2,500 or more annually, the following table describes the clauses which are included in the contract:
Appears in 1 contract
Type of Jacket. Enter the type of material of the outer jacket or sheath (polyethylene, PVC, lead, etc.) ). 54 Form D-4 Exhibit I Page 15 of 17 ----------------------------------- ----------------------------------- LICENSEE DATE ----------------------------------- ----------------------------------- BELLSOUTH LICENSE AGREEMENT NO. LICENSOR REFERENCE NUMBER (IDEALLicensee) ----------------------------------- ----------------------------------- CONDUIT OCCUPANCY APPLICATION NO. DATE INPUT INTO IDEAL ----------------------------------- ----------------------------------- AREA (Conduit Occupancy Application No.) EQUIPMENT HOUSINGS TO BE PLACED IN MANHOLES ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ Manhole Location Type Height Width Depth Weight ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------ Location ------------------------------------------------------------------------------------------------------------------------ 1 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 2 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 3 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 4 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 5 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 6 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 7 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 8 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 9 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 10 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 11 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 12 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 13 ------------ ------------ ------------ ------------ ------------ ------------------ ------------------ ----------------- --------------- -------------- ------------ 14 ------------------ ------------------ ----------------- --------------- -------------- ------------ 15 ------------------ ------------------ ----------------- --------------- -------------- ------------ ------------ ------------ ------------ ------------ 55 Form E Exhibit I Page 16 of 17 ----------------------------------- ----------------------------------- LICENSEE DATE ----------------------------------- ----------------------------------- LICENSEE REFERENCE NUMBER LICENSOR REFERENCE NUMBER ---------------------------- (IDEALLicensee) ----------------------------------- ----------------------------------- AREA DATE INPUT INTO IDEAL NOTIFICATION OF SURRENDER OR MODIFICATION OF POLE ATTACHMENT LICENSE BY LICENSEE In accordance with the terms and conditions of the License Agreement between us ------------------------------------ (BELLSOUTH LICENSE AGREEMENT NO. _______________), dated _______________, 19__, notice is hereby given that the licenses covering attachments to the following poles and/or anchors and/or utilization of anchor/▇▇▇ ▇▇▇▇▇▇ are surrendered Licensor Street Address) ------------------------------------ (or modified as indicated in Licensee's prior notification to City & State) ---------------------------------- ------------------------------------ (Licensor, dated _____________, 19__Telephone Company Name) effective __________________. ---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Assoc. Pole Number License Number License Date Surrender or Modification Date (surrender/modified) ---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- 1 A _ A/GS ---------------------------------------------------------------------------------------------------------- 2 A _ A/GS ---------------------------------------------------------------------------------------------------------- 3 A _ A/GS ---------------------------------------------------------------------------------------------------------- 4 A _ A/GS ---------------------------------------------------------------------------------------------------------- 5 A _ A/GS ---------------------------------------------------------------------------------------------------------- 6 A _ A/GS ---------------------------------------------------------------------------------------------------------- 7 A _ A/GS ---------------------------------------------------------------------------------------------------------- 8 A _ A/GS ---------------------------------------------------------------------------------------------------------- 9 A _ A/GS ---------------------------------------------------------------------------------------------------------- 10 A _ A/GS ---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Date licensor received notification: __________________ Date licensor accepted modification: __________________ By: --------------------------------------- ---------------------------------- AUTHORIZED BELLSOUTH REPRESENTATIVE AUTHORIZED LICENSEE REPRESENTATIVE ---------------------------- Poles:_______ DISCONTINUED: Anchors: _______ ---------------------------------- Anchor/Guy Strands: _______ TITLE ---------------------------- Form F Exhibit I Page 17 of 17 ----------------------------------- ----------------------------------- LICENSEE DATE ----------------------------------- ----------------------------------- LICENSEE REFERENCE NUMBER LICENSOR REFERENCE NUMBER (IDEAL) ----------------------------------- ----------------------------------- AREA DATE INPUT INTO IDEAL NOTIFICATION OF SURRENDER OR MODIFICATION OF CONDUIT OCCUPANCY LICENSE BY LICENSEE In accordance with the terms and conditions of the License Agreement between us (BELLSOUTH LICENSE AGREEMENT NO. _______________Date), dated _______________, 19__, notice is hereby given that the licenses covering occupancy of the following conduit are surrendered (or modified as indicated in Licensee's prior notification to Licensor, dated _____________, 19__) effective __________________. ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- License Number License Date Surrender of Modification Date (surrender/modified) ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- 1 ----------------------------------------------------------------------------------------------- 2 ----------------------------------------------------------------------------------------------- 3 ----------------------------------------------------------------------------------------------- 4 ----------------------------------------------------------------------------------------------- 5 ----------------------------------------------------------------------------------------------- 6 ----------------------------------------------------------------------------------------------- 7 ----------------------------------------------------------------------------------------------- 8 ----------------------------------------------------------------------------------------------- 9 ----------------------------------------------------------------------------------------------- 10 ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- Date licensor received notification: __________________ Date licensor accepted modification: __________________ By: ----------------------------------- ----------------------------------- AUTHORIZED BELLSOUTH REPRESENTATIVE AUTHORIZED LICENSEE REPRESENTATIVE DISCONTINUED: Total duct footage: ----------------------------------- ------------------ TITLE NONDISCRIMINATION COMPLIANCE AGREEMENT Contractors shall comply with the applicable provisions of the following: Exec. Order No. 12138. P L. 95-507, Exec. Order No. 11246, Exec. Order No. 11625, Section 8 of the Small Business Act as amended. Railroad Revitalization and Regulatory Reform Act of 1976. Exec. Order No. 11701, Exec. Order No. 11758, Exec. Order No. 12138, Section 503 of the Rehabilitation Act of 1973 as amended by ▇▇▇▇-▇▇▇, ▇▇▇▇▇▇▇ Era Veteran's Readjustment Assistance Act of 1974 and the rules, regulations and relevant Orders of the Secretary of Labor pertaining to the Executive Orders and Statutes listed above. For contracts of or which aggregate to $2,500 or more annually, the following table describes the clauses which are included in the contract:
Appears in 1 contract