Fillable Change of Use Permit Application (Polk County)

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Change of Use Permit Application (Polk County)

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The Change of Use Permit Application (Polk County) form is 2 pages long and contains:

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U.S.A. forms for Polk County

BROWSE POLK COUNTY (IA) FORMS

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Page 1 of 2
(time stamp)
Official Use Only
Change of Use Permit Application
All property or portion of a property that changes or converts uses to a different use
requires a Change of Use Permit. The request for Change of Use shall show that the
property or the affected part thereof, is in conformity with the provisions of the Zoning
Ordinance. The Zoning Administrator will issue the appropriate Change of Use certificate if
all of the provisions of this Zoning Ordinance have been met. The Zoning Administrator will
withhold Change of Use certificate if the requirements of the Zoning Ordinance have not
been met or if violations are present during a required site inspection of the property.
Please complete the entire application and submit with the required documentation and fee.
1. Applicant Information:
__________________________ ____________________ __________________
Applicant (Print Name) Phone Fax
_____________________________________________
Interest in Property (owner, renter, perspective buyer, etc.)
__________________________________________________________________
Address, City, State and Zip
_____________________________________________
Email
2. Subject Property Information:
_________________________________________ ______________________________
Property Address Zoning District
_________________________________________
District and Parcel Number
Legal Description (attach if necessary)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________ ____________________________________________
Current Use Previous Business Name, if applicable
____________________________________________ ____________________________________________
Proposed Use New Business Name, if applicable
3. Property Owner Consent:
The application must be signed by all the Titleholders, Contract Purchasers, Option Purchasers and other persons with
similar legal interest in the above described property. (if additional signatures are needed please attach)
_______________________________ ________
(Signature) Date
___________________________
Print Name
________
Date
_______________________________
(Signature)
___________________________
Print Name
4. Filing Fee: $98.00
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Page 2 of 2
5. Required Documentation (include with submittal):
A. Diagram (initial submittal may be a scaled drawing of
site including all existing site improvements including
buildings, paving, septic location, entrance, streets, landscaping, stormwater detention facilities, etc. Upon
review of diagram or if site improvements are required an Iowa licensed engineer certified site plan drawing
may be required).
B. A scaled floor plan drawing of interior use of the building. Upon review of plans an architect or engineer
stamped plans may be required prior to building permits being issued for the project.
C. Written description providing specific detail and reasons for the proposed change of use (Type of business
and business activities (vehicle repair, warehousing, manufacturing), % of square footage of the site or
building for proposed use, # of employees, # of shipments each day, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
D.
Detailed statement of proposed improvements
___________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
E.
Certification
I hereby certify that I have read and examined this application and know the same to be true and correct.
I owner/applicant hereby agree to comply with all statutes, ordinances, codes, regulations and rules as they pertain
to the exercising of this permit.
I owner/applicant hereby give permission for the Polk County to enter onto the property at reasonable times for
purposes of assuring compliance with any permits and approvals pertaining to this request.
I owner/applicant understand that this application must be reviewed by the Zoning Administrator, and I may not
occupy the premises until the permit has been issued. If site improvements are required, I understand that those
improvements must be completed prior to occupying the property.
I also understand that any violation of any of the above provisions may bring legal action against me by Polk
County.
___________________________________________ _____________
Signature of Applicant Date
A completed application with required documentation and filing fee must be
submitted. Incomplete submittals will not be processed.
Return form to: Polk
County Public Works, Planning & Development Division
5885 NE 14
th
Street, Des Moines, IA 50313
Phone (515) 286-3705 Fax (515)286-3437 email:PublicWorks@polkcountyiowa.gov
▪ Forms available online http://www.polkcountyiowa.gov/PublicWorks
/
OFFICIAL USE ONLY
Received by Date Received
Site improvements required Y / N Site Plan Required Y / N
Improvements completed Y / N Site Plan approved Y / N
Change of Use Approved Y / N
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Change of Use Permit Application (Polk County)

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Completed 14 February 2021

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