04/2020 cmc DNR Form 542-1355

DOCK MANAGEMENT AREA DOCK ASSIGNMENT AND PERMIT

Name of Dock Management Area: Dock Site Number:

Applicant Name: Phone Number(s):

Home Street Address:

City: State: Zip Code:

Lake Street Address:

City: State: Zip Code:

Email:

Boat Description: Boat Registration Number (example IA-1234-AB):

Are you the contact person for this dock? Yes No

If you are not the contact person, please list their name and phone number below:

This application is for (check one):

Renewal of existing - Dock Site Number:

New Permit

Change of existing permit - Dock Site Number:

SKETCH OF PROPOSED DOCK AND DIMENSIONS. Shade in the correct configuration of your dock and fill in the proper dimensions (A-E listed below). Incomplete applications will be returned to applicants.

A. Width of “L” or “T” portion.

B. Width of main dock.

C. Total length of “L” or “T” portion.

D. “Dimension D” length - length of dock from shore to point where water reaches 3’ in depth. (Only necessary if dock is more than 50’ in

total length.)

E. Total length of dock.

F. Number of hoists/lifts adjacent to dock.

DO NOT USE - FOR OFFICIAL USE ONLY

Date issued: Expires: Tenant exception: Yes No

Yearly dock fee: Applications approved by:

Yearly hoist/slip fee: Dock Management Local Authority:

Total fee collected: DNR District Supervisor:

Check No.:

04/2020 cmc DNR Form 542-1355

Winter storage of dock/hoist may be allowed. Check with the local authority on details. If winter storage is allowed, the local authority will fill in the dates allowed (below):

Winter storage allowed from: to:

The undersigned permit holder of the dock structure which is the subject of this application hereby agree that neither the Iowa Department of Natural Resources nor the State of Iowa or any political subdivision will be responsible for any injury to persons or damage to property arising out of or incident to the construction, use, or storage of such dock structure. The undersigned permit holder of the structure hereby agrees to indemnify and save the Iowa Department of Natural Resources and the State of Iowa or political subdivision harmless from any and all claims for any such injury or damage. Excepting claims for injury or damage arising from activities of the Department of Natural Resources or the State or political subdivision in the use of said structure which are being conducted exclusively for the benefit of the Department of Natural Resources, the State or political subdivision. I have read the General Rules for Dock Construction and agree to meet those requirements that are applicable to the described situation. Signature: Date:

INSTRUCTIONS

Please recheck the application to make sure that all of the required information is provided and permit fee is enclosed. Mail or deliver the application to the dock management area local authority in charge of the area where the dock is to be constructed.

The Department of Natural Resources requires proof of a $1,000,000.00 liability insurance policy on each dock

permit (attach a copy to the application). The Department strongly recommends that you warn your guests by signs

or other means, of any hazardous situations that may exist as a result of the construction or use of your dock.

The Department of Natural Resources requires a copy of your boat registration (attach a copy to the application).

Please be sure to check with the local dock management area representative regarding any dock configuration

restrictions that may exist for your area.

Please keep the dock permit available in a safe place as you must provide it upon request, to any park

ranger/conservation officer or any person you may hire to place your dock in the water.

Dock rights or privileges shall not be transferable.

No structure or inflatable device except a boat hoist may be placed adjacent to any portion of a dock. The hoist may

not be placed next to any portion of the dock greater than six feet in width.

A copy of this application with appropriate approvals will be made and returned to you and shall constitute your

dock permit.