CERTIFICATION OF COMPLIANCE WITH FLOODPLAIN REGULATIONS

Development consisting of:

( ) construction of a new building(s) ( ) construction of a new structure(s)
( ) mining operation ( ) dredging
( ) filling ( ) grading
( ) paving ( ) excavation
( ) drilling operations ( ) other (specify)________________________________________

Substantial improvement of an existing building or structure requested to be constructed

pre-improved market value of structure $______________________

market value of improvement $______________________

__________________________________________________________________________________________
(name of owner) (signature of owner)

__________________________________________________________________________________________
(property address including zip code)

__________________________________________________________________________________________
(legal description)

Property located in: Floodplain _____________ Floodway _____________

Community Panel # _____________ Date of Map _____________ Zone _____________

Base Flood Elevation _____________ MSL Required Elevation (lowest floor) of new structure _____________ MSL

Papio-Missouri River Natural Resources District recommendation attached ___________YES _________NO

Floodplain Elevation/Floodproofing Certificate Attached ___________YES _________NO

"No-Rise Certification Attached (Floodway Development ONLY) ___________YES _________NO

This permit is issued with the condition that the lowest floor (including basement floor) of any new or substantially improved residential building will be elevated at least one foot above the base flood elevation. If the proposed development is a nonresidential building, this permit is issued with the condition that the lowest floor (including basement ) of a new or substantially improved nonresidential building will be elevated or floodproofed at least one foot above the base flood elevation. The Developer/Owner will provide certification by a registered Engineer, Architect, or Land Surveyor of the "as built" lowest floor elevation (including basement ) or floodproofed elevation of any new or substantially improved building covered by this permit.

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND ALL PROVISIONS OF THE DOUGLAS COUNTY FLOODPLAIN MANAGEMENT REGULATIONS SHALL BE COMPLIED WITH.

___________________________________________________________________________________________
Signature of Developer/Owner Date

FOR DOUGLAS COUNTY USE ONLY

_________________________________________________________________________________________________________
Douglas County Official (Name and Title) Date

DEVELOPMENT PERMIT NUMBER _______________ BUILDING PERMIT NUMBER _________________

October 1999