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BUILDING PERMIT and/or SPECIAL USE PERMIT APPLICATION
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A $25 permit fee must be paid when submitting this application.. Major projects will have an additional fee and forms.
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Section I: (include owner and renter information)
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Applicant Name :
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Applicant Street Address:
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Applicant City, State, Zip:
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Applicant Cell Phone:
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Applicant Phone (Other):
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Section II:
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I/WE HEREBY REQUEST A BUILDING PERMIT TO:BUILDALTERVARIANCE(as applicable)
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THE FOLLOWING DESCRIBED PROPERTY:
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Business Name (if applicable):
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Street Address:
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City, State, Zip:
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Proposed Work:
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(ex: addition, garage, deck, fence, etc; specify
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type, size, dimensions, etc. Be as specific as possible)
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Estimated Value/Cost:
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Section III:
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(If you are requesting a special use permit, please complete this section, otherwise, skip to Section IV:)
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I/WE HEREBY REQUEST A LAND USE PERMIT TO:
CHANGE THE USE OF
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Present Use:
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Proposed Use:
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Section IV:
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Please attach and submit the following:
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1. Plan of Proposed Work (drawings of proposed work drawn to scale, including floor plans, sections, elevations, and structural
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 details as building official may require)
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2. Plot Diagram (drawn to scale with all dimensions figured, showing lot lines and exact location of all existing and proposed
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structures or, in case of demolition, of such structure as is to be demolished)
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3. Copy of Certified Survey and/or Physical Proof of lot pin locations to Councilperson or Building Official
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4. Adjoining property owners' permission for fence on property line (pertains to fences only)
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5. Specific details of business plans/objectives that might include proposed agreements or contracts (pertains to special use
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permits only) (ex: hours of operation, parking accommodations, etc)
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I have read Chapter 155, of the Code of Ordinances of Luther, Iowa, and believe to the best of my knowledge, that the work
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proposed in this application would not violate any portion of this chapter.
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Applicant's SignatureDate
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Office Use Only:
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Permit Number:
Date Approved:
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Signature of City Official:
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Fee Amount
Check # or Cash:
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