Certification Of Flood Resistant Design Form - State Of New York Page 2

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Certification of Flood Resistant Design
Premises located at: ______________________________________________________________________
Owner: ________________________________________________________________________________
Owner’s Address: _______________________________________________________________________
Floodplain Permit Application Number: ________ Municipality: _________________________________
I certify that I am a duly qualified registered professional engineer or architect licensed to practice in the
State of New York.
I certify that, based upon development and/or review of project design, specifications, and plans for
construction, the following design elements, construction methods, materials, equipment, and/or utilities are
in accordance with accepted standards of practice for meeting the applicable standards for resisting flood
damage:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Attached are the following documents that support my findings:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Certifier’s Name and Title: ________________________________________________________________
Address and Phone: ______________________________________________________________________
Professional Seal:
Type of License: ____________________________
License Number: ____________________________
License Expiration Date: ______________________
Signature: __________________________________
Date: ______________________________________
Prepared by Southern Tier Central Regional Planning and Development Board

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