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POLE ATTACHMENT APPLICATION AND PERMIT <br /> Permit No. <br /> Date: <br /> Licensee's Name: City of Decatur <br /> In accordance with the terms and conditions of the Pole License Agreement ("PLA") <br /> between Illinois Power Company and __ citv of Decatur Licensee, dated <br /> , application is hereby requested for permission to make attachments to <br /> Licensor's poles in the City/Town/Village/County of Decatur , Illinois, and vicinity, as <br /> indicated on the foregoina sketch, Exhibit A. <br /> B}r� Pa�il (lchnrna '� <br /> Typed Name/Signature <br /> PERMIT <br /> Permission is hereby granted to make the attachments described in the above application <br /> subject to all tezms and conditions mentioned above and in the PLA, and further subject to <br /> acceptance by Licensee of the obligation to pay the cost of changes or rearrangements of poles or <br /> equipment as indicated below or on a statement attached: <br /> Amount to be paid for above changes $ o <br /> Work to be completed on or before June 15, 2004 <br /> Above charges accepted <br /> (Licensee <br /> ) (Licensor) <br /> By: Paul Osborne �`r���Z� By: <br /> Typed Name/Si�nature Typed Name/Signature <br />' Title: Mayor. � y �f naratiir Title: <br /> Date: May 4, 2004 Date: <br /> 8 <br />