Polk County Public Works
5885 NE 14
th
Street
Des Moines, IA 50313
publicworks@polkcountyiowa.gov
515-286-3705
Addition to Single Family Home Building Permit Application
JOB SITE ADDRESS: ________________________________________________ TOWNSHIP: _______________________________________
GEO PARCEL: __________________________________________ DISTRICT PARCEL: _____________________________________________
OWNER: ____________________________________________________________ PHONE: _______________________________________
ADDRESS: _____________________________________________ CITY: ______________________ STATE: _______ ZIP: ________________
EMAIL: ___________________________________________________________________________________________________________
CONTRACTOR: _______________________________________________________ PHONE: _______________________________________
COMPANY: __________________________________________________________
ADDRESS: _____________________________________________ CITY: ______________________ STATE: _______ ZIP: ________________
EMAIL: ___________________________________________________________________________________________________________
Height of proposed building to peak: _________ Total # of bedrooms: _________
Is any portion of the proposed home to be used for commercial or other business activities? YES NO
*If yes, a home occupation permit must be applied for
Fill in the square footage of the proposed home in the appropriate row:
Square Feet Rate Valuation
Unfinished basement
Finished basement
1st Floor
2nd Floor
Garage
3 or 4 season room/ enclosed deck
Front Porch/Stoop- Covered/Uncovered
Total Valuation
Permit fee
Total Building
Septic Fee
TOTAL FEE
Contractor/Owner/Applicant Statement:
Work must commence within 180 days from permit issuance date, and be completed and inspected within one year from the permit
issuance date, or the building permit will be null and void. I understand all work must be inspected and approved by Polk County prior to
concealing any installation and that I must call for a final inspection. I further understand that a Certificate of Occupancy
is required in
accordance with applicable codes and ordinances.
I have included all of the above checked items and I understand that all the items listed above must be reviewed and fees paid before a
permit will be issued. I further understand that construction work cannot begin until the building permit has been issued. All information
supplied by me is true and correct, and to the best of my knowledge and belief.
I affirm I am the owner or licensed contractor of this property. I hereby acknowledge that I have read this permit and state that the
information is correct, and agree to comply with all ordinances and state and federal laws regulating activities covered by this permit.
*Please allow 5-7 business days for permit review and approval
____________________________________________ __________________________________________ _____________________
Print Name Signature Date
Permit #______________________
click to sign
signature
click to edit
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