Polk County Public Works
5885 NE 14
th
St. Des Moines, IA 50313
Ph: (515)286-3705 Fax: (515)286-3437
Email: publicworks@polkcountyiowa.gov
Mechanical Permit Application
Owner of the Job Site Property:
Job Site Address:
Parcel Number (if site has no address):
Company Name:
State Contractor License No. & Exp. Date:
Company Address (City, State, & Zip):
State Master A or B License No. & Exp. Date:
Phone Number: Email:
Permit Type (Please Check Appropriate Box)
Commercial: Residential:
Work Class (Please Check Appropriate Box)
Alteration: New Construction: Repair: Tenant Improvement:
Sub Total
Basic Fee
Total
WARNING: No LP gas appliance shall be installed in a location where heavier than air gas might collect (Basement or Pit).
The
Undersigned
Hereby
Makes
Application
To
Perform
Work
As
Described
Herein:
I
affirm
the work
described in this
application is
accurate
and
correct
to
the
best
of
my
knowledge
and
that the aforementioned license
holder is licensed to perform mechanical
work.
I
affirm
the work
described in this
application is
accurate and correct
to
the best
of
my
knowledge and that
I am the
owner
of
this dwelling
performing
work
on my
existing home or accessory building.
I
understand
work
must
commence within 180
days
from
the permit
issuance date,
and be
completed
and
inspected
within
one
year
from
the
issue date,
or
this
permit
will
be
null
and
void.
I understand all work must be
inspected and
approved by Polk County prior to concealing any installation
and I must call for the final inspection
for the mechanical permit.
I further understand
that a Certificate of Compliance is required in accordance
with applicable codes and ordinances.
_______________________________________
_______________________________________________
Print Name
Signature
Date______________
Description of Work
No.
Fee Each
Total
Air Conditioning (Residential)
Air Conditioning (Commercial)
Air Compressor
Boiler
Heat Pump/Geothermal
Heating/Air Conditioning (Roof Unit Commercial)
Heating Appliances – Installation or Relocation
Fuel Burning Fireplace, Stove or Similar Appliance
Gas Piping (1 to 6 Outlets)
Additional Gas Piping Outlets (Over 6)
Each Appliance Or Sys Not Listed Above
Permit #______________________
Name of license holder:
click to sign
signature
click to edit
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