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Exhibit A-3 - Form of Acknowledgement Letter <br />Page 1 <br />EXHIBIT A-3 <br />Form of Acknowledgment Letter [Licensee to complete and submit.] <br />[Alternative to be used if Licensee obtains all Regulatory Approvals within 365 (366 in any <br />leap year) days after Pole License is issued.] <br />[Date] <br />City of San Leandro <br />835 East 14th Street <br />San Leandro, CA 94577 <br />Attention: Michael Stella, P.E., Principal Engineer <br />Re:Pole License No. Dear Mr. Stella: <br />This letter will confirm the following: (1) that Licensee has obtained the Encroachment <br />Permit and all other Regulatory Approvals required for the Permitted Use under this Pole <br />License, copies of which are attached to this letter, as specified below; and (2) the <br />Commencement Date of this Pole License is , 20 , which is the first day of the month after <br />Licensee obtained all Regulatory Approvals. <br />This letter also confirms that Licensee has submitted all required insurance information to <br />the City. A check or surety bond for the Security Deposit (if not already provided) and the <br />License Fee for the first License Year of this Pole License is attached [or funds for the Security <br />Deposit and the License Fee for the first License Year of this Pole License have been paid to the <br />City]. <br />Please acknowledge the City’s receipt of this letter and the items listed below, and issue <br />the City’s approval for Licensee to begin installation of Equipment on the License Are by signing <br />and returning a copy of this letter. <br />Very truly yours, <br />By: <br />Title: <br />Enc. <br />[]Encroachment Permit <br />[][List other Regulatory Approvals.] <br />[][List other Regulatory Approvals.] <br />[][List other Regulatory Approvals.] <br />[]Insurance certificates and endorsements <br />[]Contractor’s bonds, insurance certificates, Business Licenses, and endorsements <br />[]Security Deposit by check, wire transfer, or surety bond, (if applicable) <br />[]First License Year’s License Fee <br />[]First License Year’s License Fee <br />[ ]Typical Photo-simulations (as applicable)