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
E
lectrical Permit Application
Owner of the Job Site Property:
Job Site Address:
P
arcel Number (if site has no address):
Company Name:
State Contractor License No. & Exp. Date:
Company Address (City, State, & Zip): S
tate Master A or B License No. & Exp. Date:
P
hone Number: Email:
Modifications of Service
Sign
N
o. Fee Each Total
Meters: 1
st
Meter
nd
2 Meter
Each Meter in Excess of Two
Circuits: First 5 Circuits
6
th
-10
th
Circuits
11
th
-100
th
Circuits
Each Circuit in Excess of 100 Circuits
Fixed Appliances at $7.70 a piece (Below - Enter Number of Each)
Ai
r Conditioner: Dishwasher:
D
ryer: Electrical Sign:
F
urnace: Heat Pump:
Ra
nge: Unit Heater:
Ot
her:
Total Number of Fixed Appliances (calculated from those listed above)
F
ixtures (Commercial Only)
Motors (Exclusive of Circuits)
S
ubtotal
Bas
ic 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
electrical 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 electrical permit. I further understand that a Certificate of Compliance is required in accordance with applicable codes and
ordinances.
_______________________________________ _______________________________________________
Print Name Signature
Date______________
Permit Type (Please Check Appropriate Box)
Commercial: Residential:
Work Class (Please Check Appropriate Box)
Additions/Alterations Meter Pedestal
New Construction Pool/Spa Service
Temporary Power Pole
Septic
Permit #______________________
Name of license holder:
click to sign
signature
click to edit