Form 542-1302 - Form Af: Construction Permit Application Fee
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3AIR QUALITY BUREAU
AF
ATTN: Application Log In
7900 Hickman Rd Ste 1
Windsor Heights, IA 50324
DNR USE ONLY
Initials:
Date:
Check/Money Order
Credit Card
Cash
F
AF: C
P
A
F
ORM
ONSTRUCTION
ERMIT
PPLICATION
EE
Facility ID:
Project #:
Please see instructions on reverse side.
Initial Payment
Additional Payment
Company Name:
Facility Number
:
(if known)
Equipment Address:
City:
1. Payment Information
Billing Contact Name*:
Billing Phone Number:
*The person to contact regarding fee payment or billing for this project.
Billing Contact Email Address:
Company Name:
Billing Address:
City:
State:
Zip Code:
2. Facility Classification
The facility is MINOR if the DNR AQB has identified the facility as a minor source for the Title V
Minor Facility
operating permit program in previous permits; or if the application is for a permit template. MINOR
facilities should complete Sections 1, 2 and 3 of this form.
The facility is MAJOR if does not fall within the above category, is a new facility, or an existing
Major Facility
facility without air quality construction permits. MAJOR facilities should complete Sections 1, 2 and
4 of this form.
3. Fee Determination: MINOR FACILITY
If selected Minor Facility above, enter the number of construction permit applications being submitted:
a. Minor Construction Permit Application(s):
x $385 = $
or
b. Permit Template(s)**:
x $100 = $
**View available permit templates at
Total Fee Due $
Check a box for your selected payment method (see the instructions for additional payment information):
Fee Enclosed - check, money order, or cash (do not send cash in the mail)
Contact for Credit Card Payment or if you are a State Agency
4. Fee Payment Agreement: MAJOR FACILITY
If selected Major Facility above: by signing on the line provided below, the applicant agrees to be billed for all fees
incurred for the review of your application at the applicable hourly rate. The applicant agrees that the applicant is liable for
application fees based on the current Fee Schedule.
Signature:
Date:
For Assistance 1-877-AIR-IOWA (1-877-247-4692)
03/2017 cmc
DNR Form 542-1302
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