2. Pursuant to Section 86-324 of the City of Daytona Beach Code of Ordinance #18-17 (hereinafter the “City Code”), every Communications Services Provider, Wireless Infrastructure Provider and Pass-Through Provider desiring to place or maintain a communications facility, conduit, backhaul facility in City right-of-way, or a utility pole used to support the location of a small wireless facility in City right-of-way, must register with the City of Daytona Beach (hereinafter the “City”) and provide the following information:
4. Company Name:
   (Name under which company will transact business in the City and, if different, in the State of Florida)
6. Business Address:
   Street address for principal place of business in Florida. If not in Florida, use address and phone # for the Company’s National Headquarters
8. City:
9. State:
10. Zip:
11. Phone #:
13. Local Representative Name:
15. E-Mail Address:
16. Phone #:
18. Emergency Contact Information (if different than Local Representative): Name:
    The local representative or emergency contact shall be available at all times. Current information regarding how to contact the local representative in an emergency shall be provided at the time of registration for the company’s registration to remain valid.
20. Email Address:
21. Phone #:
23. NOTICE: If registration is approved by the City, the following apply:
25. • Within 30 days of any change in the information above, the Registrant shall provide updated information to the City.
27. • The Registrant must renew the registration by April 1st of each year ending in “0” or “5” (such as 2020, 2025, 2030, etc.) Failure to renew may result in restricting the issuance of additional permits.
29. • Registrant shall at all times comply with and abide by all applicable codes, local laws and regulations, and State and federal laws.
31. • In addition to registering, Registrants remain responsible for obtaining any permits required by Chapter 86 of the City Code prior to commencing work in City right-of-way.
33. Type of Provider:

    (to be filled out by applicant)

    1. Communications Service Provider
    2. Pass Through Provider
    3. Wireless Infrastructure Provider
35. Other - Specify:
37. Checklist for required documents at registration:
    (to be submitted to the City at time of registration)
39. A copy of the Applicant’s certificate of authorization, public convenience and necessity, or other similar certification or licenses by the Florida Public Service Commission, the Florida Department of State, the Federal Communications Commission, or other federal authority.
40. Certificate of Authorization
42. Proof of Certificate of Insurance (COI) coverage as required in the City Code Section 86-332.
43. Certificate of Insurance
45. Checklist for required documents prior to permit issuance:
    (to be submitted to the City at time of registration)
47. Prior to issuance of any permit, the Registrant shall be required to obtain, pay, and file, with the City, a performance bond as required in the City Code Section 86-334.
48. Performance Bond
52. On behalf of the Company, the undersigned represents and acknowledges that, he or she is authorized to apply for Registration on behalf of the Company and the appropriate employee(s) for the Company has obtained and reviewed a copy of the Chapter 86 of the City Code of Ordinances.
54. Signature:
55. Date:
57. Print Name:
59. Print Title:
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

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