VILLAGE OF ALGONQUIN APPLICATION FOR SMALL WIRELESS FACILITIES PERMIT

Village of Algonquin Public Works Department

Small Wireless Facilities Permit Application

Please complete all required fields (marked with a red *) and upload required documents.

Check our website for more information: https://www.algonquin.org

Contact us at privateutility@algonquin.org or 847-658-2700.
Applicant Name*

First NameLast Name
Applicant*

Carrier/Wireless ProviderRepresentativeOther
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone Number*
Company Contact Email Address*
example@email.com
Proposed Site Property Address or Intersection in Algonquin, IL*

EXISTING POLE/STRUCTURE INFORMATION
Is this a New Pole/Structure Construction?*

YesNo
Pole/Structure ID Number*
Height of Pole/Structure (feet)*
Pole Color*
Name of Structure Owner Representative*

First NameLast Name
Existing Attachment(s) on Pole/Structure? (e.g., banners, light fixtures)*

YesNo
Existing Structure Owner*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PROPERTY OWNER INFORMATION
In the event that the proposed small wireless facility is to be attached to an existing pole owned by an entity other than the Village, the wireless provider shall provide legally competent evidence of the consent of the owner of such pole to the proposed collocation. Permission has been granted by property owner?*

YesNo
Property Owner Name*

First NameLast Name
Property OwnerAddress*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Owner Phone Number*
Property Owner Email Address*
example@email.com

Acknowledgement

I attest to the best of my knowledge and belief, that the information stated in this application and in all supporting plans and documents is true and accurate. To the best of my knowledge, I certify that the proposed collocation complies with the terms of the Collocation Requirements and Conditions Section of Algonquin s Small Wireless Facility Deployment Ordinance.
Signature

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DATE

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ELECTRONIC SIGNATURE*

First NameLast Name
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