Polk County Public Works
5885 NE 14
th
Street
Des Moines, IA 50313
publicworks@polkcountyiowa.gov
515-286-3705
515-286-3437 (FAX)
Swimming Pool Permit Application and Checklist
Please Allow 5-7 Business Days for Permit Review and Approval
JOB SITE ADDRESS: ________________________________________________
OWNER: ____________________________________________________________ PHONE: _______________________________________
ADDRESS: _____________________________________________ CITY: ______________________ STATE: _______ ZIP: ________________
EMAIL: ___________________________________________________________________________________________________________
CONTRACTOR:___________________________________________________ PHONE : _______________________________________
COMPANY: __________________________________________________________
ADDRESS: _____________________________________________ CITY: ______________________ STATE: _______ ZIP: ________________
EMAIL: ___________________________________________________________________________________________________________
Choose one (Above Ground or In Ground)
If In Ground, provide valuation: _____________
Size of proposed pool (dimensions): ________ X ________ total square feet: __________
Are you building a deck around the pool?
No
_________
______
________
________
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Print Name
________
_____
_______
________
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_________________
Signature Date
Permit #
Permit Fee: $76.00
(If yes, a separate Detached Building Per
mit application is required).
Size of proposed deck (dimensions): ________X________ total square feet: __________
Additional information (if any): ________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A barrier fence of 4’ height minimum with self-latching gate or cover meeting ASTMF-1346 is required. Please check which you
will be installing:
Barrier Fence w/Self-Latching Gate
Cover Meeting ASTMF-1346 Requirements
Checklist of items to be filled out or completed prior to submitting the application packet:
Pool permit application an
d checklist
Detailed site plan drawing
Proposed pool layout staked
Yes
Stipulations:
**No construction shall start until the permit is issued.
**All work must be permitted prior to inspections.
**Unresolved zoning, subdivision, floodplain and health items may delay the issuance of any permit. No structure should be used
or occupied until the Certificate of Occupancy/Use is issued.
**An Electrical Permit must be applied for separately by a State licensed contractor.
Contractor/Owner/Applicant Statement:
Work must commence within 180 days from permit issuance date, and be completed and inspected within one year from the permit
issuance date, or the building permit will be null and void. I understand all work must be inspected and approved by Polk County prior to
concealing any installation and that I must call for a final inspection. I further understand that a Certificate of Occupancy/Use is required in
accordance with applicable codes and ordinances.
I have included all of the above checked items and I understand that all the items listed above must be reviewed and fees paid before a
permit will be issued. I further understand that construction work cannot begin until the building permit has been issued. All information
supplied by me is true and correct, and to the best of my knowledge and belief.
I affirm I am the owner or licensed contractor of this property. I hereby acknowledge that I have read this permit and state that the
information is correct, and agree to comply with all ordinances and state and federal laws regulating activities covered by this permit.
click to sign
signature
click to edit
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