Application is hereby made for a FLOODPLAIN DEVELOPMENT PERMIT as required under Ordinance #2 passed November 16, 1982, and as amended, by the Sangamon County Board for development as defined in said ordinance. Submitted with this application is the $100 application fee. The applicant understands and agrees that:

--	the permit applied for, if granted is issued on the representations made herein;
--	any permit issued may be revoked because of any breach of representation at which time all work shall cease until the permit is reissued or a new permit is issued;
--	any permit issued on this application will not grant any right or privilege to erect any structure or use any premises described for any purposes or in any manner prohibited by the ordinances, codes, or regulations of the County;
--	construction or addition to a structure also requires a County Zoning Certificate of Compliance;
--	the applicant hereby gives consent to the Zoning Administrator, the Executive Director of the Planning Commission, or their representatives, and employees of the Sangamon County Department of Public Health to make reasonable inspections to enforce the provisions of the ordinance without first obtaining a search warrant;
--	the permit will be posted in a conspicuous place on the premises, in plain view from a public road; and
--	the permit will expire if no work is commenced within six months of issuance.

Applicant's Name ________________________________________________ Phone __________________

Address ________________________________________________ City/ Zip ______________________

Owner's Name ___________________________________________________ Phone __________________

Address ________________________________________________ City/Zip _______________________

Contractor's Name _______________________________________________ Phone __________________

Address ________________________________________________ City/Zip _______________________

Mail permit to _____________________________________________________________________________

_____________________________________________________________________________

A. Location of Proposed Development

Address ___________________________________________________________________________

Legal Description ____________________________________________________________________

__________________________________________________________________________________

Tax ID Number _____________________________________________________________________

FIRM # ________________________ Base Flood Elevation ____________________

Body of Water ______________________________________________________________________

B. Description of Development Project:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

C. Required Attachments

Exhibit #1: drawing of site, to scale, showing property line dimensions, existing elevations, proposed elevations and project boundaries by registered engineer or surveyor;

Exhibit #2: permit or waiver of permit from IDNR-OWR Permit #______________________

Exhibit #3: Engineer's Certificate (fill)

Exhibit #___: ______________________________________________________________________

I hereby certify that all the statements in and attachments to this application are a true description of the existing property and the proposed development project. I have read the development requirements of this County and agree to abide thereto.

_______________________________________________________ ____________________________
Applicant's Signature Date

do not write below this line

Permit issued: Permit number __________________ Date ___________ By _______________________
Permit denied: Date of denial letter _______________________________ By _______________________
Fee paid: $_________________
1st Inspection requested: Date __________________ Date made _____________ Initials___________
2nd Inspection requested: Date __________________ Date made _____________ Initials___________
3rd Inspection requested: Date __________________ Date made _____________ Initials___________
C of C issued: Date _____________ Inspector: __________________________________________
As-built elevation: _______________________ Location on building _____________________________

Elevation Certificate (residential or commercial structure)
Floodproofing Certificate (commercial structure only)

ENGINEER'S CERTIFICATE
(For Fill)

The undersigned, _____________________________________, Registered Professional Engineer No. _____________, does hereby certify that the drainage of surface waters will be changed by the filling of property located in the 100-year floodplain as described on the permit application and proposed to be filled in accordance with Exhibit A attached hereto, and that adequate provision has been made for collection of such surface waters into public areas or drains, which owner and developer has a right to use, and that such surface waters will not be deposited on the property of adjoining land owners in such concentration as may cause damage to the adjoining property because of the filling of said property.

_________________________________________
Registered Professional Engineer