FLOODPLAIN DEVELOPMENT PERMIT/APPLICATION
Application No. Date:
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 county/city ordinances, federal programs, and the laws and
regulations of the State of Missouri.
Owner or Agent Date Builder Date
Address Address
Phone Phone
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. 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 (100-YEAR) FLOOD ELEVATIONS.
7. Property Located in a Designated Floodplain FRINGE? Yes No
8. Elevation of the 100-Year Flood (ID source) MSL/NGVD
9. Elevation of the Proposed Development Site MSL/NGVD
10. Local Ordinance Elevation/Floodproofing Requirement MSL/NGVD
11. Other Floodplain Elevation Information (ID and describe source)
12. 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 Developer/Owner 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
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.
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.
(MISSOURI)
June 26, 2003
