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Summit County Engineering Division Flood Plain Development - Application 60 North Main ~ P.O. Box 128,Coalville, UT 84017 Coalville (435) 336-3250 ~ Kamas (435) 783-4351 x 3250 ~ Park City (435) 615-3250 Fax (435) 336-3043~ www. summitcounty.org/engineering Owner Phone # Fax # email Mailing Address City Zip Authorized Representative Phone # Fax # email Mailing Address City Zip Project Address Parcel # Section Township Range Project Description Prior Approvals (List any prior or required County approvals/permits issued for the subject property) Application Requirements: Please initial to verify commitment _____*Completed Application Form _____*Information required of Section 12-3-2 of the Summit County Code Flood Controls _____*Flood Plain Development Permit Review Fee: $100.00/unit or acre Note: Additional Information may be required for particular applications I hereby declare under penalty of perjury that this application, and all information submitted as a part of this application, is true, complete, and accurate to the best of my knowledge. Should any information or representation submitted in connection with this application be incorrect or untrue, I understand that the County may rescind any approval, or take other appropriate action. I certify that the above representative is authorized to act as my agent regarding this application. I agree to allow the County Staff, Planning Commission, or the Board of County Commissioners to enter the subject property to make inspections thereof. I also agree to file an Elevation Certificate with FEMA and the County Engineer’s office prior to requesting Certificate of Occupancy from the Building Dept. Signature FOR OFFICE USE ONLY Date Filing FEMA FIRM Map # ___Completion Application ___Approved (Flood Plain Admin.) ___Other Agency Approval ___Additional Info. Requested ___Additional Info. Received ___Elevation Certificate