Flood Plain Development Permit/application Form

FLOOD PLAIN DEVELOPMENT PERMIT/APPLICATION

___________________

_________________

Application No.

Date Received in Office

TO THE ADMINISTRATOR: The undersigned hereby makes application for a permit to develop in a floodplain. The work to be performed, including flood protection works, is as

described below and in attachments hereto. The undersigned agrees that all such work shall be in accordance with the requirements of the Floodplain Management Ordinance

and with all other applicable municipal ordinances, federal programs, and the laws and regulations of the Commonwealth of Pennsylvania. I certify that the Code official or his

representative shall have the authority to enter the property and structures, at any reasonable hour during the permit process, to enforce the provisions of the Codes & Ordinances

governing this project. I understand and assume responsibility for the establishment of official property lines for required setbacks prior to the start of construction, and agree to conform to

all applicable laws of this jurisdiction. I further certify that this information is true and correct to the best of my knowledge and belief.

Signature of Owner or Authorized Agent

Date

Print Name

Email

Complete Address (Street, City, State, Zip)

Phone

Cell

Builder, Contractor, Company

Person in Charge

Date

Email

Complete Address (Street, City, State, Zip)

Phone

Cell

SITE DATA

Municipality: ______________________ County: _________________ Tax Parcel/I.D.#___________________

On the property tax notice

Address:

Street

City

State

Zip

►►Please submit additional information on additional sheet(s) if needed.◄◄

Additional sheet(s) attached

1.

Type of Development:

Filling

Grading

Excavation

Minimum Improvement

Routine Maintenance

Substantial Improvement

New Construction

Other: _____________________

2.

Description of Development: ____________________________________________________________________________________________

____________________________________________________________________________________________________________________

3.

Premise Details: Structure Size ___________ ft. by ___________ ft. Area of Site: ___________________ Sq. Ft.

Principal Use: _________________________________

Accessory Use (storage, parking, etc.):________________________________

4.

Value of Improvement (fair market value): $___________________ Pre-Improvement/Assessed Value of Structure: $_____________________

5.

Property Located in a Designated FLOODWAY?

YES

NO

IF ANSWERED YES, CERTIFICATION MUST BE PROVIDED INDICATING THE PROPOSED DEVELOPMENT WILL RESULT IN NO INCREASE IN THE BASE (100-YEAR)

FLOOD ELEVATIONS, PRIOR TO THE ISSUANCE OF A PERMIT TO DEVELOP

6.

Property Located in a Designated Floodplain FRINGE?

YES

NO

7.

Elevation of the 100-Year Flood (ID source): _________________________________________________________________________NGVD

8.

Elevation of the Proposed Development Site: _________________________________________________________________________NGVD

9.

Local Ordinance Elevation/Flood proofing Requirement: ________________________________________________________________NGVD

10. Other Floodplain Elevation Information (ID and describe source): ______________________________________________________________

___________________________________________________________________________________________________________________

Other Permits Required:

11.

US Army Corps of Engineer 404 Permit:

YES

NO

PROVIDED

DEP Permit:

YES

NO

PROVIDED

Environmental Protection Agency NPDES Permit:

YES

NO

PROVIDED

Building Permit per PA Uniform Construction Code:

YES

NO

PROVIDED

All Provisions of Ordinance Number: ______________________, the “Floodplain Management Ordinance,” shall be in Compliance.

Official Use Only

PERMIT APPROVAL/DENIAL

Plans and Specifications:

Approved

Denied this _______________ Day of ___________________________, 20______

THIS PERMIT IS ISSUED WITH THE CONDITION THAT THE LOWEST FLOOR (INCLUDING BASEMENT FLOOR) OF ANY NEW OR SUBSTANITALLY IMPROVED

RESIDENTIAL BUILDING WILL BE ELEVATED__________________FOOT/FEET ABOVE THE BASE FLOOD ELEVATION. IF THE PROPOSED DEVELOPMENT IS A NON-

RESIDENTIAL BUILDING, THIS PERMIT IS ISSUED WITH THE CONDITION THAT THE LOWEST FLOOR (INCLUDING BASEMENT) OF A NEW OR SUBSTANITALLY

IMPROVED NON-RESIDENTIAL BUILDING WILL BE ELEVATED OR FLOODPROOFED________________________FOOT/FEET ABOVE THE BASE FLOOD ELEVATION. ALL

OTHER LOCAL, SATE, AND FEDERAL PERMITS THAT MAY BE REUQIRED ARE THE RESPONSIBILITY OF THE APPLICANT TO OBTAIN AND COMPLY WITH.

THIS PERMIT IS USED WITH THE CONDTION THAT THE DEVELOPER/OWNER WILL PROVIDE CERTIFICATION BY A REGISTERED ENGINEER, ARCHITECT, OR LAND

SURVEYOR OF THE “AS-BUILT” LOWEST FLOOR (INCLUDING BASEMENT) ELEVATION OF ANY NEW OR SUBSTANTIALLY IMPROVED BUILDING COVERED BY THIS

PERMIT.

Signature of Municipal Official/Agent

Date

Print Name and Title

(

Rev 4-20-15 PMCA – rcm)