FLOODPLAIN DEVELOPMENT PERMIT/APPLICATION
Application No.: Date:
TO THE ADMINISTRATOR: The undersigned hereby makes application for a permit to develop in the Special Flood Hazard Area
(SFHA) or “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 county/city ordinances, federal programs, and the laws and regulations of the State of Missouri.
O
wner or Agent Date Builder
Address Address
T
elephone Number
Telephone Number
SITE DATA
1. Location: 1/4; 1/4; Section ; Township ; Range
Street Address:
2
. Type of Development: Filling Grading Excavation Minimum Improvement
Routine Maintenance Substantial Improvement New Construction Other
3. Description of Development:
4
. Premises: Structure Size ft. By ft. Area of Site Sq. Ft.
Principal Use: Accessory Uses (storage, parking, etc.):
5. Value of Improvement (fair market): $ Pre-Improvement/Assessed Value of Structure: $
6. Is the Property Located in a Designated FLOODWAY? Yes No
IF ANSWERED YES, CERTIFICATION MUST BE PROVIDED PRIOR TO THE ISSUANCE OF A PERMIT TO DEVELOP, THAT
THE PROPOSED DEVELOPMENT WILL RESULT IN NO INCREASE IN THE BASE (1%) FLOOD ELEVATIONS.
7. Is the Property Located in a Designated Floodplain FRINGE or a Floodplain (SFHA) without a Designated FLOODWAY? Yes No
8. Elevation of the 1% Base Flood (ID source) NGVD/NAVD
9. Elevation of the Proposed Development Site NGVD/NAVD
10. Community Ordinance Elevation/Floodproofing Requirement NGVD/NAVD
11. NFIP Flood Insurance Rate Map Panel(s) Number(s)
1
2. Other Permits Required? Corps of Engineer 404 Permit: Yes No Provided
State Department of Natural Resources 401 Permit: Yes No Provided
Environmental Protection Agency NPDES Permit: Yes No Provided
All Provisions of Ordinance Number , the “Floodplain Management Ordinance”, shall be in Compliance.
PERMIT APPROVAL/DENIAL
Plans and Specifications Approved/Denied this Day of , 20
Signature of Prop
erty Owner or Agent Authorizing Official
Print Name and Title Print Name and Title
THIS PERMIT IS ISSUED WITH THE CONDITION THAT THE LOWEST FLOOR (INCLUDING BASEMENT FLOOR) OF ANY
NEW OR SUBSTANTIALLY 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 SUBSTANTIALLY
IMPROVED NON-RESIDENTIAL BUILDING WILL BE ELEVATED OR FLOODPROOFED FOOT/FEET ABOVE THE
BASE FLOOD ELEVATION.
THIS PERMIT IS USED WITH THE CONDITION 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.
(MISSOURI)
August 1, 2015
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