STATE OF ILLINOIS

DEPARTMENT OF TRANSPORTATION

DIVISION OF AERONAUTICS

PROPOSED CONSTRUCTION PERMIT REQUEST

Name of Individual or Company

Making Request

Address

Street

City

Zip

Phone

Nature and Description of Proposed Structure:

New Construction

Alteration

Nearest Town:

Location from Nearest Town

Direction

Distance

Nearest Airport:

From Nearest Point to a Runway

Distance

Direction

Latitude

Longitude

°

'

"

°

'

"

PROPOSED HEIGHTS AND ELEVATIONS

Site Elevation (Mean Sea Level)

Feet

Highest Point of Structure Above Ground

Feet

Overall Height above Mean Sea Level

Feet

Estimated Construction Starting Date

Estimated Construction Completion Date

Type of Structure:

Permanent

__________

Temporary

___________

Will Structure be Obstruction Lighted:

Yes

________________

No

_________________

Will Structure be Obstruction Marked:

Yes

________________

No

_________________

Remarks:

Date:

Title or Position:

Signature