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
M
echanical Permit Application
Owner of the Job Site Property:
Jo
b Site Address:
P
arcel Number (if site has no address):
Company Name:
S
tate Contractor License No. & Exp. Date:
Company Address (City, State, & Zip):
S
tate Master A or B License No. & Exp. Date:
Phone Number: Email:
P
ermit Type (Please Check Appropriate Box)
C
ommercial: Residential:
Wo
rk Class (Please Check Appropriate Box)
Alteration: New Construction: Repair: Tenant Improvement:
S
ub Total
B
asic Fee
T
otal
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______________
D
escription of Work
N
o.
F
ee Each
T
otal
Air Conditioning (Residential)
A
ir Conditioning (Commercial)
A
ir Compressor
Boiler
H
eat Pump/Geothermal
H
eating/Air Conditioning (Roof Unit Commercial)
Heating Appliances – Installation or Relocation
F
uel Burning Fireplace, Stove or Similar Appliance
G
as Piping (1 to 6 Outlets)
Additional Gas Piping Outlets (Over 6)
Ea
ch Appliance Or Sys Not Listed Above
Permit #______________________
Name of license holder:
click to sign
signature
click to edit
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