APPLICATION FOR FIRE SPRINKLER INSTALLATION PERMIT
Building Address:
General Contractor/ Owner:
Fire Sprinkler Company: Company Phone Number:
Licensed Fire Sprinkler Installer: Iowa License #:
Certified Iowa Extinguishing System Contractor:
Contractor License #:
Scope: New Installation Modify Existing System
Fire Protection System: Alternate SystemStand PipeFire Sprinkler Commercial Cooling System
Dry‐Chemical Clean Agent Other
Fire Protection Standard: NFPA 13 NFPA 13D U.L. 300Stand PipeNFPA 13R
Type of Protection System: Wet Dry OtherWet & Dry
Description of Work:
Total Square Feet Number of Stories Number of Risers
No. of Sprinkler Zones Number of Sprinkler Heads Size of Underground
*Value of Sprinkler Installation $
*The value shall be the total value of all work for which the permit is issued.
(The value should be equal the contract amount for the project.)
Permit fee schedule ‐ Fire Sprinkler Permit fees will be paid by the licensed Installer and/or Their Company.
Value of Sprinkler Related Work Permit Fee
$1-500 $37.00
$501-2,000 $2.27/per hundred over 500 +$37.00
$2,001-25,000 $10.47/per thousand over 2,000 + $71.05
$25,001-50,000 $7.64/per thousand over 25,000 +$311.86
$50,001-100,000 $5.34/per thousand over 50,000 + $502.86
$100,001-500,000 $4.11/per thousand o ver 100,000 + $769.86
$500,001-1,000,000 $3.53/per thousand o ver 500,000 + $2,413.86
>$1,000,000 $2.33/per thousand over 1,000,000 + $4,178.86
NOTICE: Separate permits are required for building, electrical, plumbing, heating, and air conditioning, or signs. This
permit becomes null and void if work or construction authorized is not commenced within 180 days, or if construction or
work is suspended or abandoned for a period of 180 days at any time after work is commenced.
I agree to perform the work described herein in accordance with the plans and/or specifications submitted, and with all
provisions of the Building Code of Polk County, IA.
TOTAL PERMIT FEE $
Signature of Applicant Date
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