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Home My WebLink AboutFEMA Application 2002-9-24 ;.- ..-\ ._-"- , ...- FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE O.M.B. No. 3067-0077 Expires July 31, 2002 ImDortant: Read the Instructions on eages 1 - 7. SECTION A. PROPERTY OWNER INFORMATION BUILDI~~f~~G~E~ p:- A-~ BUILDING STREET ADgRESS ~mg Apt, Unit, SuIt9, 8f1dIor Bldg. No.) OR P.O. ROUTE AND BOX NO. ttz:1!:! "2 :::.2.~/ r. !!7 ~ !:- t-:J ' . CITY spe.\t->~naO D~~f</) PROP~ IT DESCRlPlIUN (Lot arnl 61_ NumberS, lax Parcel NUmber, UlQOl Desa1ptlon, etc.) . \'I 02-'~ l \ I..-a-r 1 ~ t:?P.o BUILDING USI:: (e.g~esldentia( NllIHll5(oenllal, Adaition, ~. etc. Use a Cdmmen1s area, ~ necessary.) , ~6SIOK~IA< _. . LAT11UOEILONGITUOE (oPTiONAL) HORIZONTAL DATUM: SOUR~ l-J GPS (Type)" ( I#f'-#If -##.#If' ex ##.##IIIIIf') LI NAD 1927 LI NAD 1983 LI USGS Quad Map LI Other SECTION B - FLOOD INSURANCE RATE ~ (FIRM) INFORMATION , ~1. NAP c;;oMMUNfTY ~E &COMMUNfTY NUMBER B2. CPUNIY ~E I B3. ~~ . . C,-j. ,,-t ,^ '. ' SS91. [..AI-.} G" v 1'i,:~7~~~~ I~~FLX:.~~~~ EFFE~~~~DATEI ~O~~D ~el~1~~~f~~~) , Bl0. Indicate the source of the Base Flood Elevation (BFE) data or base ~ood depth entered in B9. , " 1-1 Fls Profile.. ik1 FIRM ' 1-1 Community Determined, '1-1 Other (Describe): ' Bll: In,Ucate the elevatloricli.tum used for the BFE In B9: ~NGVD 1929 1-1 NAVD 19B8 1-1 Other (Describe): B12. Is the bulldln910cated In a Coastal Barrier Resources'system (CBRs) area or Otherwise P._;~_;~J Area (OPA)7 1-1 Yes 1-1 No Designation Date' SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevatio~s are based on: LIConstruction Drawings. I-IBulldlng Under Construction. , iPlfiniShed Construction" . A new Elevation Certificate will be required when construction of the building is complete. ' . C2. Building Diagram Number.J:2. (Select the building diagram most similar to the building for which this certificate is being completed. see pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) C3. Elevations - Zones Al-A30, AE. AH, A (with BFE), VE, Vl-V30, V (with BFE), AR, ARJA, ARlAE. ARlAl-A30, ARI/>J-l, ARlAO Complete Items C3.a-1 belovi according to the building diagram specified In Item C2. State ihe datum used. If the dalum is different from the datum used for the BFE in Section B, conVert the datum to that used for the BFE. Show field measurements and datum conversion calculation. Use the space provided or the Comments area of Section 0 or Section G, as appropriate, to document the datum cOnversion. : " Datum Conversion/Comments' _ Elevation reference mark used 1512... D Does the eievation refe~ence mark used appear on~PAOl~1 No [J a) Top of bottom floor (Inciudlng basement or enclosure) l';llOil .511:.ft.(m) -: ~~(~\'N'~ \l~ [J b) Top of next higher floor ._ft.(m) 11 C{j; ~ ~~ ~ [J cJ Bottom of lowest horizontal structural '!lember ry zones only) . -:- ft.(m) ; ~ ~~~ 54 22PE ~ ~ [J d) Attached garage (top of slab) - . ~ i ?, . =tBfl(m) i ~ ,1-. 1\ ':- _ [J eJ Lowest elevation of machinery and/or equipment ' ~: ~ ," ,\WJLJ(; ~ servicing the bullcllng (Describeln a Comments area.) '-'"2 I? .1...~(m) i l ~ OREGON# [J f) Lowest adjacent (finished) grade (LAG)'. ., , 17/'0 . ft.(m) ~ ~ ~ '1~'4 ,'t ~ [J g) Highest adjacent (finished) grade (HAG) ,t:;K . 7;" ft.(m) . ~ /?y ,'5 ~ ~-ql [J h) No. of permanent openings (fi~d vents) within 1 ft. above adjacent grade l~ ~ /4 S. 11\\.\.<:; Ibkt [J i) Total area of all permanentopemngs (flood vents) In C3.h 'o-j'" 0 sq. In. (sq. cm) a, SECTION D. SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICAn!3iii<PII'iATlDN DATE: 6/3010-; 1- This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the Information In Sections A, B, and C on this certlficete represents my besf efforts to interpret the data available. I understand that anv false statement mav be ounlshable bv fine or Imorlsonment under 18 U.S. Code. Section 1001. C~TIF{:"~~LA ""J btlL-l.."::>Tl2-vtv\ P-E:., UCENSI::NUMB~ ?Lje~z... Ph fi'i'u: I- COM<'f\NY N<I1<t= . , t;:: N "'-I /..:J E 1312- ~Oe:rl8J::- E:o """"trJ ~&O,/2.J. ~b ADDRl:~I1C'<l~ P6 L. 'Vl . I?u~~e. ~ . ~~I SIGNATUREH-il '" _ ,JUI11:L~ Jl..Q..ctifi,------- 4.t.l'l/^ z.. 9-I~ _PI1:f~ LI- CI C eu I=I=MA I=rvm A'1..:~1 ,1111 M -. ~F=i= R~~. ~Ini= I=nR t"'.nNTINIIATlnN RI=PI A~i=.C:: All PRl=V1nll.C:; I=nITlnN~ .. - IMPORTANT: In theaespaces, CODY the correspondlno Information frnm :'lection A , BUILDING STREET A."ur=o.; (InciooIng'Apt., UnIt, sliie. andIorBldg. No.) ORP~6:ROlJTE,AND'BOX NO. ,E'OC;lnsutai1Cli;"=nv'!\!Is.:<;ij"'''''~ ........_"'_~~~i~'2~ ~"'r.Numlii$_-. ~-. ."~il'~ ~~~"", ".~~~ ,- ,-- - . ..:. . .~' ~ ZIP CODE 'Go . NAlG"'umbe """"'" """~ ~, ' ~~,'7.~"iif="""!!:'f, ...,'.~~j SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) , " Copy boih sides of this Elevation Certificate for (1) community official, (2) Insurance agent/company, and (3) building owner. COMME:NT~ STATE CITY 1~1. Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zone AO and Zone A (without BFE), complete Items El. through E4. If the Elevation Ce,rtlficate Is, intended for use as supporting Information for a LOMA or LOMR-F, Section C must be completed. , " , E 1. Building Diagram Number -'-- (Select the building diagram most similar to the building for which this certificate Is being completed - see pages 6 and.7. If no diagram accurately represents the building, provide a sketch or photograph.) , , E2. The top of the bottom fioor Oncluding basement or enclosure) of the building is LLI ft.(m) LLlin.(cm) LI above or LI below (check one) the highest adjacent grade. (Use natural grade, If available.) " " , " ' , , , E3. For Building Diagrams 6-8 with openings (see page 7), the next higher fioor or elevated fioor (elevation b) ot'the building Is LLI ft.(m) LLlln.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form. ' E4. For Zone AO only. If no fiood depth number Is available, Is the top olthe bottom fioor eleVated In accordan'ce with the cOmmunity's fioodnlain manaoement ordlnance?LI Yes t-l No LI Unknown. The local official must ce~ this Information in SectionG. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION , The property owner or owne~s authorized representative who completes Sections A, B, C (Items C3.h and C3.1 only), and E for Zone A (without a FEMA-issued or community-issued BFE) or Zone AO must' sign here. The statements in Sections A, B, C, and E are correct tei .J!!e best of my knowledge. ' '_ PROPERTI OWNER'S OR OWNER'S AlITl10RIZED REPRESENTATIVE'S NAME AUURESS CllY . STATE ZIP CODE .SIGNA TURf: DATE TELEPHONE COMMENTS I I Check here If attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who Is authorized by law or ordinance to administer the community's fioodplaln management ordinance can complete Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable Item(s) and sign belOw. , Gl. LI The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, engineer, or architect wh'o Is authorized by state or local iaw to certify elevation information. (Indicate the source and date of the elevation data In the Comments area below.) G2. LI A community officlal completed Section E for a building located In Zone A (without a FEMA-Issued or community-lssued BFE) or ZoneAO. ". ' G3. LI The following information (Items G4-(9)is provided for'community fiOOdplaln management purposes. G4, PERMfT NUM6ER I G5. DATE PERMIT ISSUED I G6. DATE CERTIFICATE OF COMPUANCEJOCClJPANCY . ISSUED'" G7. This permtl has been issued for: LI New Construction LISubstantiallmprovement Ga. Elevation of as-bul~ loweSt fioor Oncludlng basement) of the building is: G9. BFE or (in Zone AO) depth of flooding at the builcllng site Is: LOCAL Ol'f-ICIAL'S NAME . _ ft.(m) Datum: , . _ ft.(m) Datum: TITLE COMMUNITY NAME SIGNATURE TELEPHONE DATE COMMENTS I_I Check here if attachments FF=MA Fnrm A1_~1 .1111 nn RFPI Ar;:.~ All PR~lnll~ FnlTlnl\J~