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FLOOD PLAIN DEVELOPMENT PERMIT Application Page 1 of 2 DALLAS COUNTY OFFICE of PLANNING and DEVELOPMENT 907 Court Street I Adel, IA 50003 I [PHONE REDACTED] I [EMAIL REDACTED] TO THE 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 Dallas County Flood Plain Management Ordinance and with all other applicable county ordinances and the laws and regulations of the State of Iowa. Project Location (E-911 Address) (City/Post Office) (Township Name) (Section Number) (Subdivision Name) (Lot Number) (Latitude) (Longitude) (PIN [list all that apply]) (Other) Owner Information (Name) (Mailing Address/P.O. Box) (City/Post Office) (State) (Zip) (Phone) Home Work Mobile (Email Address) Contractor Information (Company/Name) (Mailing Address/P.O. Box) (City/Post Office) (State) (Zip) (Phone) Home Work Mobile (Email Address) Description of Development (Please describe the proposed development) Type(s) of Development (check all that apply): Filling New Construction Routine Maintenance Excavation Grading Substantial Improvement Minor Improvement Other (please describe): (Size of Site [ft. x ft.]) (Area of Site [sq. ft.]) (Estimated Cost) (Principal Use) (Accessory Uses [storage, parking etc.]) Addition or modification to non-conforming use: Yes No Assessed value of structure (if “Yes”): ---PAGE BREAK--- FLOOD PLAIN DEVELOPMENT PERMIT Application Page 2 of 2 DALLAS COUNTY OFFICE of PLANNING and DEVELOPMENT 907 Court Street I Adel, IA 50003 I [PHONE REDACTED] I [EMAIL REDACTED] THIS PERMIT IS ISSUED WITH THE CONDITION THAT THE LOWEST FLOOR (INCLUDING BASEMENT) OF ANY NEW OR SUBSTANTIALLY IMPROVED RESIDENTIAL BUILDING WILL BE ELEVATED AT LEAST 1.0 FOOT ABOVE THE 100 YR. (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 FLOOD PROOFED TO AT LEAST 1.0 FOOT ABOVE THE 100 YR. (BASE) FLOOD ELEVATION. All provisions of the Dallas County Flood Plain Management Ordinance (Chapter 40, Dallas County Code of Ordinances) shall be complied with. THIS PERMIT IS ISSUED 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. (Signature of Applicant) (Date) Flood District Information (Please provide the following details) Is property located in a designated Floodway (FW District)? Yes No IF “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 100 YEAR (BASE) FLOOD ELEVATION. Is property located in a designated Floodway Fringe (FF), General Flood Plain (FP), or Shallow Flooding (SF) District? Yes No If “Yes”, indicate which one: Elevation datum used: NAVD88 NGVD29 Other Elevation of the 100 year (Base) flood Source: Elevation of the proposed development site (natural ground) (ft): Required elevation/flood proofing elevation for lowest floor (ft): Proposed elevation/flood proofing level for lowest floor (including basement): Other information (identify and describe source): Other Permits Required Iowa DNR Flood Plain Permit Yes No Permit # Date Received: US Army Corps of Engineers Yes No Permit # Date Received: Other Yes No Permit # Date Received: S I G N H E R E