Fillable POLK COUNTY FLOOD PLAIN DEVELOPMENT PERMIT/APPLICATION TO THE (Polk County)

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POLK COUNTY FLOOD PLAIN DEVELOPMENT PERMIT/APPLICATION TO THE (Polk County)

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POLK COUNTY FLOOD PLAIN DEVELOPMENT PERMIT/APPLICATION
Application # Date: ______________________
TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit to
develop in a flood plain. 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 done
in accordance with the requirements of the Zoning Ordinance for the Unincorporated Polk County,
Iowa, Article 7, Division 4, Section 1. Floodplains and with all other applicable County ordinances
and the laws and regulations of the State of Iowa.
___________________________________ ___________________________________
Owner or Agent Date Builder/Contractor Date
___________________________________ ___________________________________
Address Address
Telephone___________________________ Telephone___________________________
1. Location _____ 1/4, _____ 1/4, Section _____, Range _____, Township _______
Street Address ________________
If available, District # _______________ Parcel # __________________
and exact legal description: ___________________________________________________
_________________________________________________________________________
2. Type of Development:
Filling _______ Grading _______ Excavation _______ Routine Maintenance ______
Minor Improvement ______Substantial Improvement ______New Construction _______
3. Description of Development: _________________________________________________
_________________________________________________________________________
4. Premises: Size of Site __________ ft. x __________. Area of site ___________________
Estimated cost $
Principal Use__________________________________
Accessory uses (storage, parking, etc.)___________________________________________
5. Addition or modification to nonconforming use? Yes __________ No __________
Assessed value of structure $______________
6. Property located in a designated "Floodway" (FW District)? Yes ________ No ________
IF ANSWERED YES, CERTIFICATION MUST BE PROVIDED PRIOR TO THE ISSUANCE OF A PERMIT
TO DEVELOP, THAT THE PR
OPOSED DEVELOPMENT WILL RESULT IN NO
RISE/INCREASE IN THE
BASE FLOOD (100-YEAR) ELEVATION.
7. Property located in a designated Floodplain (FP), Floodway Fringe (FF), or Shallow Flood
(SF) District? (If yes, please circle the area that applies.) Yes__________No__________
a. Elevation of the Base (100-year) Flood ft. NGVD
b. Elevation/flood proofing requirement
ft. NGVD
c. Elevation of the proposed development
ft. NGVD
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 1.0 FT.
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 1.0 FT.
ABOVE THE BASE
FLOOD ELEVATION.
8. Source of Base Flood Elevation Data if not available on FIRM _______________________
_________________________________________________________________________
Panel number of FIRM ______________________________________________________
9. Other permits required?
Corps of Engineers 404 permit: Yes _____ No _____
Iowa Department of Natural Resources: Yes _____ No _____
Other ____________________________________________________________________
All provisions of the Polk County Flood Insurance Study, shall be complied with.
THIS PERMIT IS ISSUED WITH THE CONDITION THAT THE DEVELOPER/OWNER WILL PROVIDE, IF
REQUIRED, 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 AND/OR STRUCTURE COVERED BY THIS PERMIT.
Plans and specifications approved this _______day of __________________, 20_______.
________________________________ _____________________________
Signature of Developer/Owner Authorizing Official
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POLK COUNTY FLOOD PLAIN DEVELOPMENT PERMITAPPLICATION TO THE (Polk County)

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Completed 14 February 2021

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