CITY OF ROCK FALLS BUILDING PERMIT
3 South Nottingham Street, ROCK FALLS, IA 50467

APPLICATION FOR ZONING CERTIFICATE

APPLICANT __________________________________________________________________

ADDRESS __________________________________________________________________

APPLICATION IS FOR (CIRCLE ONE)

NEW BUILDING ALTER BUILDING ADD TO BUILDING REPAIR BUILDING

ON THE FOLLOWING DESCRIBED PREMISES:

QUARTER __________ SECTION __________ TOWNSHIP __________ RANGE __________

LOT (S) _________________ BLOCK ___________SUBDIVISION ______________________

OTHER DESCRIPTION _________________________________________________________

LOT SIZE:
WIDTH:
FRONT (STREET) ___________________ REAR _____________________________

DEPTH ____________________________ AREA _____________________________

SETBACKS TO LOT LIMIT:

_______ FEET FROM RIGHT OF WAY LINE _______ FEET FROM REAR LOT LINE

______ FEET AND _________ FEET FROM EACH SIDE LOT LINE

HEIGHT OF STRUCTURE: STORIES ________________ FEET _______________

MAXIMUM AMOUNT OF ORDINARY PROJECT OF SILLS, BELTCOURSE, CORNICES,
ORNAMENTAL FEATURES AND ROOF OVERHANG _________________________

TYPE OR PURPOSE OF IMPROVEMENT PROPOSED ________________________

SIZE OF STRUCTURE _________________________ SQUARE FOOT AREA ______________

NUMBER OF ROOMS ______________________ NUMBER OF FAMILIES _________________

CONSTRUCTION COST $ ________________________ PERMIT FEE $20.00 DUE WITH
APPLICATION TO CITY OF ROCK FALLS

THE UNDERSIGNED APPLICANT CERTIFIES UNDER OATH AND UNDER THE PENALTIES
OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT.

DATE _____________ APPLICANT SIGNATURE ___________________________________

ATTACH A SKETCH OF LOT OR TRACT WITH DIMENSIONS OF SAME. ALSO DRAW
PROPOSED BUILDING INDICATING THE SIZE OF SAME, AS WELL AS SHOWING DISTANCES
FROM ALL BOUNDARY LINES.