Residential Applicationto Develop

In a Flood Hazard Area

Property Owners Name: (Last) (First) (Middle) DL# State

Mailing Address: //

(# & Street Name (or) P.O. Box # & Route # & Box #) (City) (Zip)

Telephone Number://

(Home/Mobile) and(Work) and(E-mail)

Site Address: //

* 911 Address Required* (# & Street Name (or) P.O. Box # & Route # & Box #) (City) (Zip)

Lot/Tract______, Block/Section ______, Subdivision ______, Unit #

Acreage______, Survey Name ______, Abstract ______, Deed Volume ______, Page

Instrument # ______, GEO Number:

NATURE OF PROPOSED CONSTRUCTION (check and complete as appropriate):

 Residential  Other Placement of Fill  Natural Waterway Alteration or Drainage Course

DESCRIPTION OF PROPOSED CONSTRUCTION(check and complete as appropriate):

 New Construction  House  Substantial Improvement to Existing Structure  Mobile Home sq. ft. ______

 Other: sq. ft. ______

FOUNDATIONS OF PROPOSED CONSTRUCTION(check appropriate box): Stilts/Columns/Piers  Fill Dirt  Slab

Briefly describe the development. If additional Space is needed, attach a form:

Base Flood Elevation (BFE) at development site: ft above MSL

Option or Non-Residential: elevation of flood proofing to proposed structureftabove MSL

WARNING: Please read & acknowledge: The Flood Insurance Rate Maps (FIRM) and other flood data used by the Harrison County Floodplain Administrator in evaluating flood hazards to proposed developments are considered reasonable and accurate for regulatory purposes and are based on the best available scientific and engineering data. On rare occasions greater floods can and will occur and flood heights may be increased by man-made or natural causes. Issuance of a permit to develop in a flood hazard area does not imply that development outside the identified areas of special flood hazard will be free from flooding or flood damage. Issuance of this permit shall not create liability on the part of HarrisonCounty, the countyFloodplain Administrator, or any department, officer, or employee of HarrisonCounty in the event flooding or flood damage does occur.

**APPLICANT WILL PROVIDE ONE COPY OF DETAILED PLANNING MATERIALS FOR PROPOSED CONSTRUCTION, IF IN FLOODPLAIN**

Signature of Applicant: ______Date:

PERMIT APPROVAL (PA) GRANTED BY:

LICENSE NO.: ______DATE:

A COPY OF THIS APPLICATION WITH APPROVAL SIGNATURE ON LINE (PA) BY THE CERTIFIED FLOODPLAIN MANAGER SHALL SERVE AS A“PERMIT”APPROVAL TO DEVELOP, BASED ON PLANNING MATERIALS RECEIVED BY THIS DATE.

CERTIFICATE OF COMPLIANCE(COC) GRANTED BY:

LICENSE NO.: ______DATE:

A COPY OF THIS APPLICATION WITH APPROVAL SIGNATURE ON LINE (COC) BY THE CERTIFIED FLOODPLAIN MANAGER SHALL SERVE AS “Certificate of Compliance”OF THE DEVELOPMENT, BASED ON FINAL DEVELOPMENT INSPECTION, TO INCLUDE ANY APPROVED CHANGES OR MODIFICATIONS MADE AFTER RELEASE OF PERMIT APPROVAL.

FPA Form 4-26-2012