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2. This is a food establishment certification of 1) No change to facilities or 2) Renovations/Alterations to facilities
4. It is the responsibility of the food establishment to disclose information on renovations and alterations to the City of Dubuque. Alterations found during inspections not previously submitted to the City of Dubuque will result in a penalty. Please indicate below, any renovations or alterations made in the plumbing, menu, appliances, or any other changes that correlate to the fats, oils, and grease (FOG) program:
6. Name of establishment*
8. Permit #:*
   As indicated on current permit or hauler manifest. If the permit number is unknown, call 563-589-4176.
10. Renovations/Alterations
    Please indicate any below:
12. Plumbing*
    -- Select One --YesNo
14. Summary of Plumbing Alterations
16. Menu*
    -- Select One --YesNo
18. Summary of Menu Alterations
20. Appliances (subtraction/addition)*
    -- Select One --YesNo
22. Summary of Appliance Alterations
24. Other*
    -- Select One --YesNo
26. Summary of Other Alterations
28. Establishments that have made any renovations or alterations must fill out a revised permit application and submit this application to the City of Dubuque. Applications can be found at www.cityofdubuque.org/fog under the Helpful Documents tab.
30. By checking this box, I certify, under the penalties of law, that the contents of this application to the best of my knowledge including my kitchen fixtures and layout are accurate and complete.*

    1. I agree
32. Owner/Authorized Representative Name*
34. Title*
35. Date*
37. The permit process is not considered complete until this form AND payment are received.
    Please refer to the invoice for amount due.
39. Payment methods:
    Mail a check payable to City of Dubuque to:
    Water & Resource Recovery Center
    795 Julien Dubuque Dr.
    Dubuque, IA 52003
    OR
    Pay by credit card by calling 563-589-4176
40. Your permit will be mailed to your establishment once this form and payment are processed.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field