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.
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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
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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
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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 _____________
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