CITY OF CORALVILLE

URBAN CHICKEN PERMIT APPLICATION

Failure to complete all sections of the application and provide supporting documentation will result in a denial of your application.

APPLICANT INFORMATION [PLEASE PRINT]

Name: __________________________________________________________________________________________________________

Address: ________________________________________________________________________________________________________

Home or Cell Phone: _____________________________________________________________________________________________

**24-hour emergency contact phone number: _____________________________________________________________________ This is the number that will be called if we receive a complaint about the chickens on your property.

INITIAL EACH ITEM

______1) I have read the Coralville Urban Chicken Ordinance and understand the requirements for keeping chickens.

______2) I am aware that I am responsible for keeping chickens within the confines of my property at all times.

______3) I am aware that I must receive approval from the City prior to obtaining chickens.

______4) I will follow all City ordinances and state laws relating to the care and keeping of animals.

______5) I acknowledge that I live in a single family dwelling located on a lot zoned for residential use.

______6) I understand that the permit is a limited license for activity and no vested zoning rights arise from the permit being

issued and that the permit does not run with the property.

______7) I understand that any private restrictions on the use of the property shall remain enforceable and shall supersede

the permit.

______8) I grant the right for City staff to inspect my property prior to approval of this permit and at any time to investigate

a complaint.

______9) I have successfully completed the required urban chicken training and attached a copy of the certificate.

______10) I acknowledge that all chickens must be banded in accordance with procedures established by the City.

______11) I understand only hens are allowed and not more than six (6) licensed chickens are permitted per property.

______12) I understand this permit is only valid for a period of one calendar year and shall expire December 31st of each year.

______13) I understand that all chickens shall be secured in a coop from dusk to dawn.

______14) I understand City ordinance requires certain construction materials and minimum requirements for the coop

enclosure.

I affirm that all statements contained in the application are true and correct and that I the permit holder will keep the chickens in compli-

ance with all related ordinances and Urban Chicken Policy. I understand that failure to comply with regulations may result in revocation

of the permit and/or issuance of a municipal infraction.

Signature: _________________________________________________________ Date: ________________________________________

*A tenant shall attach to this application written permission from the landlord to keep chickens on the property. Own Rent*

Mail forms with supporting documents AND payment to: Coralville Police Department| PO Box 5911| Coralville, IA 52241. Check or money order only. Make payable to Coralville Police Department.

1

CITY OF CORALVILLE

URBAN CHICKEN PERMIT APPLICATION

Describe the chicken coop and pen including the materials used and total cubic feet.

Sketch a diagram below of the property including the dimensions and:

• Identify the adjacent properties by street address

• Indicate the location of coop and pen

CHICKEN COOP DESCRIPTION & MATERIALS

CHICKEN COOP LOCATION & PROPERTY INFROMATION

2

URBAN CHICKEN PERMIT APPLICATION

CITY OF CORALVILLE

Failure to complete all sections of the application and provide supporting documentation will result in a denial of your application. LANDLORD APPROVAL FORM —FOR TENANTS ONLY

TO BE COMPLETED ONLY IF THE APPLICANT IS A TENANT.

I am the owner/landlord of __________________________________________, Coralville, Iowa, AND I give permission for my tenant,

____________________________________________________________, to install a chicken coop and keep chickens on the property.

——————————————————— Owner/Landlord [Printed]

_____________________________________________________ ___________________________

Signature of Owner/Landlord Date

3

Permit Application Fee: $25 Paid ________

City Permit Approval: Date:______________ Official:_____________________________

City Inspection: Date:______________ Official:_____________________________

Meets Requirements: Yes _______ No _______ Corrections Needed _______

Reason (s) for Denial: __________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

1st Band Number _________________________ $5.00

2nd Band Number ________________________ $5.00

3rd Band Number ________________________ $5.00

4th Band Number ________________________ $5.00

5th Band Number ________________________ $5.00

6th Band Number ________________________ $5.00

Total: ________

Notes: _________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

CITY OF CORALVILLE

URBAN CHICKEN PERMIT APPLICATION

FOR CITY STAFF USE ONLY

PERMIT APPROVAL FORM

CHICKEN ID LEG BANDS

PERMIT NUMBER: ______________________________________

ISSUE DATE: ___________________________________ EXPIRATION DATE: December 31, 20____

ISSUED BY: ______________________________________

Subscribed and sworn before me by________________________________ At Coralville Iowa on _____________

4