Polk County Public Works
5885 NE 14th Street
Des Moines, IA 50313
Phone: 515-286-3705 FAX: 515-286-3437
Email: publicworks@polkcountyiowa.gov
SINGLE TRIP PERMIT APPLICATION
Single Trip
-
$
35
Round Trip - $70
Requested Start Date:
Vehicle Owner or Lessee:
Contact Name Phone No. ____________________ Cell: _____________
Address: US DOT Number
FAX No. ______________________ MC No. ___________
(Valid For One Power Unit Only)
City, State, Zip Code
FAX No. ______________________ MC No. ___________
Carrier Type:
For Hire
Private
Email Address: Iowa Interstate Authority Number:
NATURE OF LOAD: Briefly describe the Articles (s) being Transported
SME Qualified? Yes No
POWER UNIT & TRAILER INFORMATION
POWER UNIT- Both Plate, State, and VIN must be identified
Plate
Year
S Vehicle Identification Number (VIN)tate
Power Unit Registered Info
Year
MMaakkee
TRAILER- Both Plate & State must be identified
StatePlate Make Other (if necessary)
DIMENISIONS/WEIGHT
Overall Trailer Load Rear ProjectionFront Projection
Length
Width
Height
AXLE WT/SPACING - front to rear (required when gross weight exceeds 80,000 lbs)
Axle No. 1 2 3 4 5 6
Gross Wt.
Axle Spacing
Axle No. 7 8 9 10 11 12
Gross Wt.
7 -8 8 - 9 9 - 10 10 - 11 11 - 12
Axle Spacing
Beginning Address Ending Address
ROUTE (List all roads)
CERTIFICATION MAILING ADDRESS IF DIFFERENT FROM ABOVE
Acceptance of Condit NAMEions: I hereby certify that the information contained in this
is true and correct and that I will comply with the attached General Provisions
Mailing Address
X __________________________________________ ___________________
Customer or Authorized Agent Date METHOD OF ISSUANCE
FAX EMAIL MAIL
Polk County Approval: Date of Approval: Permit Expires sunset of
General Provisions
2. This permit issued under authority of Section 321E of the Iowa Code. Permit not valid on primary roads or within corporate limits of any municipality
3. Mover shall comply with terms and conditions of the permit, take all reasonable precautions to protect and safeguard lives and property of traveling public and adjacent
property owners, and shall hold the issuing authority(ies) harmless of any damages that may be sustained on account of such move.
4. Nothing in permit shall be construed as waiving load limitations which have been established on any bridge or any road posted with embargo signs.
1.
shall take steps
to avoid and reduce traffic congestion
maintaining
traffic interval,
relinquishing the traveled
in
to
provide a passing opportunity for the following vehicles desiring to travel faster than the prescribed speed of the permit vehicle. This should be done as soon as
conveniently possible after a group of two or more vehicles have accumulated in back of the permit vehicle.
8. Mover shall furnish such escorts as may be required by Statute and operate in safe manner and at the appropriate posted speed limit or lower if required.
given permit is required and is public information. Failure to complete the application as required will result in denial of permit. Permit issuing authorities will not
Disclosure Statement: The information furnished on this application will be used by Polk County to prepare and issue permits. All information applicable to a given
7. Movement is allowed only from sunrise to sunset unless it is determined by the issuing authority that the move can be made more safely at another time because of the
traffic-volume conditions. Movement is allowed seven days a week except for designated holidays and for special events when abnormally high traffic counts can be
excepted. The designated holidays are: Memorial Day, Independence Day, and Labor Day. No movement will be allowed on these holidays or after 12 Noon on days
preceding these holidays and holiday weekends which include holidays that fall on Monday, except as provided for in Section 321.457 of the Code
4. Nothing in permit shall be construed as waiving load limitations which have been established on any bridge or any road posted with embargo signs.
6. No vehicle or combination of vehicles of illegal dimensions with or without load shall be moved on Polk County roads without permit.
5. Permit and any supplements or additions thereto shall be void in case the weights or dimensions of the vehicle and load as operated exceed the weights or dimensions as
provided in the permit and supplements or additions thereto
Form: Annual OS Permit.xls
Revised: 23/12/2015
Attach Route Map
be responsible for any damages that are the result of the move. Polk County and any other permit issuing authority resume no responisbility for the property of
given permit is required and is public information. Failure to complete the application as required will result in denial of permit. Permit issuing authorities will not
the permit holder.
Weight
DDoes Applicant have public Certificate of Insurance ($100/200/50) on file with this office?
With IA DOT Office of V & MC Services?
Escrow Acct.
Check/Cash
Payable to: Polk County Public Works
