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U.S. Department of Transportation
Federal
Aviation Administration
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Failure To Provide All Requested
Information May Delay Processing of Your Notice
Notice of Proposed Construction or
Alteration
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FOR FAA USE ONLY
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  1.
Sponsor (person, company, etc. proposing this action) :
Attn. of:
Name:
Address:
City: State: Zip:
Telephone: Fax:
2. Sponsor's
Representative (if
other than #1) :
Attn. of:
Name:
Address:
City: State: Zip:
Telephone: Fax:
3.
Notice of: New Construction Alteration Existing
4.
Duration: Permanent Temporary ( months, days)
5.
Work Schedule: Beginning End
6.
Type: Antenna Tower Crane Building Power Line
Landfill Water Tank Other
7.
Marking/Painting and/or Lighting Preferred:
Red Lights and Paint Dual - Red and Medium
Intensity White
White - Medium Intensity Dual - Red and High Intensity White
White - High Intensity Other
8.
FCC Antenna Structure Registration Number (if applicable):
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9. Latitude: ______ ° ______ ' ______ . ______ "
10. Longitude: ______ °
______ ' ______ . ______ "
11. Datum:
NAD 83 NAD 27 Other
12. Nearest:
City: State:
13. Nearest Public-use (not private-use) or Military Airport
or Heliport:
14. Distance from #13. to Structure:
15. Direction from #13. to Structure:
16. Site Elevation (AMSL): ft.
17. Total Structure Height (AGL): ft.
18. Overall height (#16. + #17.) (AMSL): ft.
19. Previous FAA Aeronautical Study
Number (if
applicable):
- OE
20. Description of Location: (Attach a USGS 7.5 minute
Quadrangle Map with the precise
site marked and any certified survey.)
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Notice is required by 14 Code of Federal Regulations, part
77 pursuant to 49 U.S.C., Section 44718.
Persons who knowingly and willingly violate the notice requirements of
part 77 are subject to a civil penalty of $1,000 per day until the notice is
received, pursuant to 49 U.S.C., section 46301 (a).
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I hereby certify that all of the
above statements made by me are true, complete, and correct to the best of my
knowledge. In addition, I agree to
mark and/or light the structure in accordance with established marking and
lighting standards as necessary.
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