Northeast Texas Municipal Water District

ALL PERMIT

FEES ARE NON- Permit Number REFUNDABLE Non-Residential/Commercial Application to Develop In a Flood Hazard Area

Company/Owner Name: (Last) (First) (Middle) DL# State Mailing Address: / / (# & Street Name (or) P.O. Box # & Route # & Box #) (City) (Zip) Telephone Number: / / (Mobile) and (Work) and (E-mail) Site Address: / / *Site Address or GPS coordinates Required * (City) (Zip)

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

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

Instrument # ______, GEO Number: NATURE OF PROPOSED CONSTRUCTION (check appropriate box):  Non-Residential  Other  Placement of Fill  Natural Waterway Alteration or Drainage Course DESCRIPTION OF PROPOSED CONSTRUCTION (check off and complete as appropriate):  New Construction  Substantial Improvement to Existing Structure  Non-Residential (specify): Sq. Ft. ______ Industrial (specify): Sq. Ft. ______ Gas & Oil: 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 for Non-Residential: elevation of flood proofing to proposed structure ft above 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 Harrison County, the county Floodplain Administrator, or any department, officer, or employee of Harrison County 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 Owner or Authorized Representative: ______Date: (If not the owner will need proof of Representatives authorization) 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:

FPA Form 1-27-2012 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 1-27-2012