FLOODPLAIN DEVELOPMENT PERMIT APPLICATION 5909 N. Milwaukee River Parkway Glendale, WI 53209 414-228-1711 Ph. I. Identification II. Applicant Name Mailing Address: street, city, state, zip Phone Owner Contractor I hereby certify that the proposed work is authorized by the owner of record and that I, acting as agent, have been authorized by the owner to make this application. Signature of Applicant Date of Application I. II. Type and Selected Characteristics of Construction, Development or Improvement III. A. Construction or Development Type Construction or Development Details: Residential Public Utility Commercial Government/Municipal New Construction Addition Floodproofing Alteration Repair-Replacement Demolition/Moving (circle one) Filling/Grading/Excavating Other: (please specify) Utilities: Electric: Above-ground Underground Sewer & Water: Public Private Private Well On-site: Yes No Additional Facilities: III. Proposed Development Information IV. At (address or location): Subdivision: Lot: Block: Lot Size: Is NOT located in a Special Flood Hazard Area Is partially located in a SFHA, but building/development is not. Is located in a Special Flood Hazard Area (Floodfringe) Firm Panel No.: Firm Zone Designation: 100-year flood elevation at site is: ft. NGVD (MSL) Is located in the Floodway (See additional information required in Section X.) Firm Panel No.: 100-year flood elevation at site is: Firm Zone Designation: ft. NGVD (MSL) Page 1 of 6
IV. Brief Description of Proposed Project Estimated Starting Date: Estimated Completion Date: Estimated Total Cost: $ (Estimate subject to City review and verification) (Estimated cost of project MUST include the following: All materials, labor, built-in appliances, overhead, and profit, repairs made to damaged parts of the building at the same time, building, electrical, plumbing, HVAC, and demolition costs.) Description of the Project: (Example: This project consists of a 400 sq. foot addition, and master bedroom and bathroom remodel. The addition construction consists of a crawlspace and conventional framing, floodproofing, and landscape restoration.) Note: If the proposed work involves the modification, alteration, reconstruction or improvement of any kind to an existing structure located within an identified flood-prone area, the building official may require an estimate of the market value for that structure in order to determine the extent of construction spending limits and floodproofing required. Estimated Market Value of Structure: Market Value Determination Source: $ (appraisal, assessed value, etc.) V. Site or Plot Plan REQUIRED FOR ALL APPLICATIONS Attach a CURRENT Plat of Survey or Site Plan showing the exact size and location of the proposed activity as well as any existing buildings, structures or appurtenances. REQUIRED WHEN APPLICABLE Accurately delineate any area that is subject to flooding and the location of any existing stream improvements or protective works. Provide adequate documentation showing the extent of protection provided by such improvements or works. Submit copies of all plans and construction specifications for any proposed stream improvement or protective works as well as all State and Federal approvals and permits. NOTE: Any property mapped within the 100-Year Flood Recurrence Interval must submit an accurate survey indicating the location of the floodplain boundary (floodway/floodfringe) as it relates to the property including a topographic survey. This area intentionally left blank Page 2 of 6
VI. Minimization of Flood Damage Describe the methods and materials that will be used to minimize flood damage in accordance with all applicable local, state and federal requirements. Attach plans and elevations in sufficient detail to enable the Permit Officer to determine that the proposed work will meet such applicable requirements. VII. Fees Estimated Total Cost (See Glendale Fee Schedule under Ordinance Section 15.1.21) VIII. Approval or Disapproval IX. DO NOT WRITE BELOW THIS LINE I have determined that the proposed activity: A. IS B. IS NOT In conformance with the provisions of Ordinance Section 13.2. The permit is issued subject to the conditions attached to and made part of this permit. Other Permits Required: Yes No If yes, check below Electrical HVAC Plumbing Occupancy Early Start Razing Erosion Control Signature of Floodplain Administrator: Date: IX. Reason for Disapproval Proposed activity in the above application is disapproved because of the following: If Box A is checked, the Local Floodplain Administrator may issue a Development Permit upon payment of designated fees. If Box B is checked, the Local Floodplain Administrator will provide a written summary of deficiencies included above. Applicant may revise and resubmit an application to the Local Floodplain Administrator or may request a hearing from the Board of Appeals. Page 3 of 6
APPEALS: Appealed to Board of Appeals: Yes No Hearing Date(s): Appeals Board Decision: Approved Denied Reasons/Conditions: X. Additional Information Required (Per Section III) XI. A site plan showing the location of all existing structures, water bodies, adjacent roads, lot dimensions and proposed development. Development plans, drawn to scale, and specifications including where applicable: details for anchoring structures, proposed elevation of lowest floor (including basement), types of water-resistant materials used below the first floor, details of floodproofing of ALL utilities located two feet above the BFE, and details of enclosures below the first floor. Also, Subdivision or other development plans. (If the subdivision or other development exceeds 50 lots or 5 acres, whichever is the lesser, the applicant must provide 100-year flood elevations if they are not otherwise available. Plans showing the extent of watercourse relocation and/or landform alterations. Lowest floor elevation including basement, crawl or attached garage slab (in feet). Must be a minimum of three ft. above BFE. YES NO Change in water elevation ft. NGVD (MSL) Meets ordinance limits on elevation increases (Increase of 0.01 feet or less is permitted.) YES NO Top of new compacted fill elevation. Fill height extends a minimum of 15 feet from foundation perimeter. YES NO Floodproofing protection level (in feet). Meets ordinance limits on elevation increases (Increase of 0.01 feet or less is permitted.) YES NO For floodproofed structures, applicant must attach certification from registered engineer or architect. XI. As-Built Elevations XII. The following information must be provided for structures that are part of this application. This section must be completed by a registered professional engineer or land surveyor (attach certification to this application. Complete 1 and 2 below: 1. Actual (As-Built) elevation of the top of the lowest floor is: NVGD (MSL) 2. Actual (As-Built) elevation of floodproofing protection is: NVGD (MSL) Page 4 of 6
XII. Compliance (To be Completed by Local Floodplain Administrator) XXI. Inspection History: 1. Date: By: Deficiencies? Yes No 2. Date: By: Deficiencies? Yes No 3. Date: By: Deficiencies? Yes No 4. Date: By: Deficiencies? Yes No Inspection Notes: (Numbers correspond with inspection dates above.) 1. 2. 3. 4. Certification of Design And Construction This proposed design and construction of the referenced building, including foundations, floodproofing, and placement of the lowest floor, meet the applicable standards contained in the community s floodplain management ordinance (Section 13.2). The methods used in making the necessary loading calculations and in selecting the appropriate design and construction materials reflect currently acceptable engineering practices. Any modifications to these specifications and plans will invalidate this certification. I hereby certify that the proposed activity has been adequately designed to protect against flood damage and that the plans for the construction, development and improvement of the site are in compliance with all rules and regulations of the City of Glendale concerning construction within an identified flood-prone area. Seal Signature of registered engineer or architect Print Name Address Phone Date Page 5 of 6
XIII. Plan Review (To be Completed by Local Floodplain Administrator) XII. I. All Development - Base Flood Elevation Data provided. A. The as-built elevation certification from a registered land surveyor or professional engineer has been submitted? Yes No B. The lowest floor elevation is at or above the required lowest floor elevation? Yes No C. Electrical, heating, ventilation, plumbing, air conditioning equipment (including duct work) and other service facilities are located above BFE or floodproofed? Yes No II. Development in Zones A, AE, AH, AO, AR, A99, Zone V, Zone VE. A. Solid foundation perimeter walls located below BFE: 1. There are at least two (2) openings? Yes No 2. Square footage of enclosed area subject to flooding 3. Square inches of venting required 4. Square inches per opening (multiply l by w) 5. Number of required vents (3 above divided by 4 above) 6. Foundation contains the minimum number of vents? Yes No 7. The bottom of each opening is no higher than one (1) foot above grade? Yes No 8. Any cover on openings will permit the automatic flow of floodwaters in both directions? Yes No B. Floodway data is provided. 1. Did this development encroach in the floodway? Yes No 2. Do the actual field conditions meet the proposed actions and technical data requirements? Yes No 3. If B-1 was "yes", has a No-Rise Certification been submitted? Yes No Reviewer's Name: Date reviewed: Local Administrator's Signature: Date: Page 6 of 6 Created: 06/10
City of Glendale Department of Building Inspection 5909 N. Milwaukee River Parkway Glendale, WI 53209 414-228-1711 Ph. D E V E L O P M E N T P E R M IT _ P ro p e rty A d d ress _ P ro je c t D e s c rip tio n IS S U E D T O : _ A D D R E S S : IS S U E D B Y : _ D A T E : E x p ire s : T h is p e r m it m u s t b e p o s t e d o n t h e p r e m is e s in a c o n s p ic u o u s p la c e s o a s to b e c learly v is ib le from th e s treet.