he undersigned hereby makes application for a permit to develop in a designated floodplain area. The
work to be performed is described below and in attachments hereto. The undersigned agrees that all
such work shall be done in accordance with the requirements of the Town of Burgaw Floodplain
Ordinance and with all other applicable local, State and Federal regulations. This application does not
create liability on the part of the Town of Burgaw or any officer or employee thereof for any flood
damage that results from reliance on this application or any administrative decision made lawfully
Applicant: Builder/Surveyor/Engineer (if applicable):
Property Owner: Telephone:
Address or Location of Property:
Pin Number:
. Structural Development:
Activity Structure Type
New Structure Residential (1-4 Family)
Addition Residential (More than 4 Family)
Alteration Non-residential (Floodproofing? Yes)
Relocation Combined Use (Residential & Commercial)
Demolition Manufactured (Mobile) Home
Replacement In Manufactured Home Park? Yes
Estimated Cost of Project $ Assessed Value $
If Addition/Alteration, year existing structure constructed
B. Other Development Activities:
Clearing Fill Mining Drilling Grading
Excavation (Except for Structural Development Checked Above)
Watercourse Alteration (Including Dredging and Channel Modifications)
Drainage Improvements (Including Culvert Work)
Road, Street or Bridge Construction
Subdivision (New or Expansion)
Individual Water or Sewer System
Other (Please specify)
Description of Work: (To be completed by Applicant)
The Applicant, hereby certifies that all statements herein and attachments to this application are to the best of my
knowledge, are true and accurate.
Applicant’s Signature: Date:
e proposed development is located on FIRM Panel No. , Dated
FBFM Panel No. (if applicable) Dated
e Proposed Development:
Is NOT located in a Special Flood Hazard Area (Notify the applicant that the application review is
complete and No Floodplain Permit is required)
Is partially located in the Special Flood Hazard Area, but building/development is not.
Is located in a Special Flood Hazard Area (100-Year Floodplain) - FIRM zone designation is
100-Year base flood elevation at the site is: ft. NGVD (MSL)
Lowest Floor Elevation (with 2ft freeboard) is: ft.
Unavailable (If BFE is unavailable, elevation of the lowest floor and all utilities must be
constructed to be 4 foot above highest adjacent grade)
Elevation Certificate Required FEMA Form 81-31
s located in the floodway.
No-Rise Certification Required
he applicant must submit the documents checked below before the application can be processed.
A site plan showing the location of all existing structures, water bodies, adjacent roads, lot
dimensions, and proposed development.
evelopment plans, drawn to scale, and specifications, including where applicable: details for
anchoring structures, proposed elevation of lowest floor (including basement), elevation of
lowest duct work, elevation of lowest equipment (including electrical), flood vents for water
flow (two per side located within 1’ of outside grade with a total of 1”square opening per each
sq. ft. of enclosure), foundation mortar (surewall with fiber for drystack in cases of mobile
homes), types of water-resistant materials used below the first floor, details of floodproofing of
utilities located below the first floor, and details of enclosures below the first floor.
levation Certificate Required FEMA Form 81-31
o-Rise Certificate Required Certification from a registered engineer that the proposed
activity in a regulatory floodway will not result in any increase in the height of the “100-Year”
flood. A copy of all data and hydraulic/hydrologic calculations supporting this finding must also
be submitted.
loodproofing Certificate (non-residential)FEMA Form 81-65
lease see attached sheet for additional requested information.
(Certifications not required the following structures within Zone A, AO, AE, or A1-30 Recreation Vehicles meeting requirements of Section 8-
17(6)(a); Temporary Structures meeting requirements of Section 8-17(7); or Accessory Structures less than one hundred fifty (150) square feet
meeting requirements of Section 8-17(8) of the Town of Burgaw UDO.)
Floodplain Determination (To be completed by the Floodplain Administrator)
Additional Information Required (To be completed by Floodplain Administrator)
Floodplain Administrator Signature: Date:
have determined that the proposed activity: A. Is
B. Is Not
n conformance with provision of the Town of Burgaw Floodplain Ordinance. The permit is issued
subject to the conditions attached to and made part of this permit.
If Box B is checked, the Floodplain Administrator will provide a written summary of deficiencies.
Application may revise and resubmit an application to the Floodplain Administrator or may request a
hearing form the Board of Adjustment.
PPEALS: Appealed to Board of Adjustment? Yes No
Hearing Date:
BOA Decision Approved? Yes No
The following information must be provided for structures that are part of this application.
Elevation Certificate FEMA 81-31 (Pre-Built Elevation) required prior to the actual start of any
new construction. Date Received:
Elevation Certificate FEMA 81-31(Reference Level)- is required within seven (7) calendar days
after the reference level is established. Date Received:
levation Certificate FEMA 81-31 (As-Built) is required after construction is completed and
prior to certificate of Compliance/Occupancy issuance. Date Received:
Approved Proposed Elevations
This approval is issued subject to any conditions attached to and made part of this permit. As-Built
elevations must be provided to obtain a Certificate of Occupancy.
Town of Burgaw Floodplain Administrator Date
Permit Determination (To be completed by Floodplain Administrator)
Floodplain Administrator Signature: Date:
Elevations (To be submitted by Applicant before Certification of Compliance/Occupancy is issued)
The Floodplain Administrator will complete this section as applicable based on inspection of the project
to ensure compliance with the Town of Burgaw’s Floodplain Ordinance.
nspections Date: By: Deficiencies? Yes No
Date: By: Deficiencies? Yes No
Date: By: Deficiencies? Yes No
Approval: As-Built Elevations
As-Built elevations have been submitted, reviewed, and approved. This Floodplain Development Permits
is issued in conformance with Article 8 of the Town of Burgaw Unified Development Ordinance.
Town of Burgaw Floodplain Administrator Date
Compliance Action (To be completed by Floodplain Administrator)