Floodplain Development Permit Application Page 4
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APPLICATION #_____________
PAGE
SECTION 5: PERMIT DETERMINATION
(To be completed by LOCAL FLOODPLAIN
ADMINISTRATOR)
I have determined that the proposed activity: A. □ Is
B. □ Is not
in conformance with provisions of Local Law #_________, (yr)______. This permit is herby issued subject to
the conditions attached to and made part of this permit.
SIGNED__________________________________, DATE_______________________________
If BOX A is checked, the Local Floodplain Administrator may issue a Development Permit upon payment of
designated fee.
If BOX B is checked, the Local Floodplain Administrator will provide a written summary of deficiencies.
Applicant may revise and resubmit an application to the Local Floodplain Administrator or may request a hearing
from the Board of Appeals.
APPEALS: Appealed to Board of Appeals? □ Yes □ No
Hearing date:__________________________
Appeals Board Decision: Approved? □ Yes □ No
Conditions:
______________________________________________________________________
______________________________________________________________________
SECTION 6: AS-BUILT ELEVATIONS AND CERTIFICATIONS
(To be submitted by APPLICANT
before Certificate of Compliance is issued)
Certification of as-built elevations must be provided for project structures. Attach an Elevation Certificate or
Floodproofing Certificate completed by an authorized professional or official and complete 1 or 2 below.
1.
Actual (as-built) elevation of the top of the lowest floor, including basement, is: _______ Ft. □ NGVD
1929 / □ NAVD 1988 / □ other datum (describe) _____________________________________________
or __________ Ft. above highest adjacent grade. Attach Elevation Certificate, FEMA Form 81-31.
2.
Actual (as-built) elevation of dry floodproofing protection is ________ Ft. □ NGVD 1929 / □
NAVD 1988 / □ other datum (describe) _____________________________________________.
Attach Floodproofing Certificate, FEMA Form 81-65.
Attach any additional certifications that are required to document compliance. These may include: “no-rise”
certification, certification of flood resistant design, certification of soil compaction, non-conversion agreement, etc.
SECTION 7: COMPLIANCE ACTION
(To be completed by LOCAL FLOODPLAIN
ADMINISTRATOR)
The LOCAL FLOODPLAIN ADMINISTRATOR will complete this section as applicable based on inspection
of the project to ensure compliance with the community's local law for flood damage prevention.
INSPECTIONS:
DATE____________BY_____________________________DEFICIENCIES? □ YES □ NO
DATE____________BY_____________________________DEFICIENCIES? □ YES □ NO
DATE____________BY_____________________________DEFICIENCIES? □ YES □ NO
SECTION 8: CERTIFICATE OF COMPLIANCE
(To be completed by LOCAL FLOODPLAIN
ADMINISTRATOR)
Certificate of Compliance issued: DATE: _____________ BY: ______________________________________
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