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
Plumbing 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: Water Service:
Backflow Preventer: Sewage Eject:
Dishwashers: Sinks:
Drinking Fountains: Sump Pumps:
Floor Drains: Tub/Showers:
Garbage Disposals: Urinals:
Grease Traps: Water Closets:
Lavatories:
Water Heaters:
Roof Drains:
Water Softeners:
Fixtures Not Listed:
Total Number of Fixed Appliances (Calculated from those listed above)
Reconstruction – Drain, Stack, Vent
Subtotal
Basic Fee
Total Fee
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 plumbing
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
plumbing
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
Water
Service
– Change, Disconnect,
Installation,
Repair (PLEASE CIRCLE ONE)
Is
any
work
proposed
within
the
road
right
of
way?
Yes
No
(If yes, then a Right-of-Way
Use
Grant
Permit
is
also
required.)
Sewer Service – Installation, Change or Repair If this is a new sewer connection, a
Sanitary Sewer Connection Permit must also be completed.
Fixtures
at $7.60 a piece (Below
-
Enter Number of Each)
Permit #______________________
Name of license holder:
Sand/Oil Interceptor:
click to sign
signature
click to edit
![]()
