HomeMy WebLinkAboutFEMA Application 2002-6-28
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eERAL EMERGENCY MANAGEMENT A Ay
NATIONAL FLOOD INSURANCE PROG':1ff
ELEVATION CERTIFICATE
.
Important: Read the ins~~t~c:ns.~~ pages 1 - i.
SECTION A - PROPERTY U~~.~: INKJRMAnON
BUILDING OWNER'S NAME
BUILDING STRE:T ADDRESS (Incuding Apt, Unit Suile. and/or Eldg. No.) OR P.O. ROUTi:AND SUA NV.
~74~ :Jarnb Lo~~ _
CITY . ('. . ST"8f<2..
<:::"LP'( ~ 11' <: \d . ....._
P~+-7Y DECbRiPTION ILot and Blod< Numoers. Tax P=I 1'<l1llICUI. ~esc:iption. =J
\ \,e:y i L<'i.II1dI,^~ 1"'4 MA, , _,'.. ,
BUILDING USE. (e.g., ~identi;1l. Non-residential, Addition, Accessory, etc. Use c,rrunenrs.5eCXl.u II r1ews:sc;ry.)
1?l'?oSC ~\Q<:'\ . _n. .__._ '_ _..
LATITUDEilONGITUDE (OPTIONAl) HORIZONTAl UAI UM: "UU",""" U U?~ (i'ype),
( 11#" - #If -11#.11#" or 1I#.###IIIf') U HAD 1927 U NAn 1983 . U USGS Quad Map
O,M,B. No. 3067-0077
Expires July 31, 2002
I For InsWClnce Company Use:
I Poiic/ Number
I Company NAIC Numb~r
ZlP CO~ 7 4'7 '7
U Other.
.. ,
SECTION B - FLOOD INSURANCE RAIE MAP (ARM) INFORMATION
Bl. N, FIP COMIj\UNIlY NAME & COMMUNITY NUMBER 52 COUNTY NAMh . I 83. STATE ,0
('l~_~ S0"""'&if.;et 4-15;; z, L4"'P LOu""T"! ...:' df<'....
I 84. MAP AND PANEL I ss: SUFFix B6. FIRM INDEX I B7. ARM PANEL 88. FLOOD ,- 89. BASE FLOOD ELEVATlON(SJ
NUMBER DATE EFFECTIVE1REV1SEDDATE ZONE(S) (ZoneAO. use depth offlooding)
LlIO-::jqc...\ \(Ap 'P' T~'lolq1q :::r~t, l11Q. AE 513.5
B10. Indicate the source ~8ase Flood 8evation (8FE) data or base flood oepth enler.!d in 89.
U FIS Profile RM " U Community Determined . U Other (Desenbe):
Bl'. Indicate the elevation datum used for the BPE in 89: ~ NGVD 1929 U NAVD '~ U Other (Descnbe):
812. Is the building located in a Coastal Barrier Resources System (CBRS) area or CthenoJSe Protected Area (OPA)? U Yes ~o
Designation Date: .
. ' SECTION C. BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) ,
~. Building elevations are based on: UConstruc:ion Drawings" ~Building Under Construction" UFinished ConStruction
"A new Elevation Certificate ~I be required when construction of the building is compie!e., .
C2. Building Oiagram Number -11- (Select the bUDding diagram most similar to the building for whicil this cenrncate is being completed _ see
pages 6 and 7. If no diagram accurately represents the building. provide a sketc!l or photograph.)
C3. Elevations-Zones A1-A3D, AE, AH, A (with BFE). VE. V1-V30. V (with BPE). AR.AAJA. ARlAE. ARlA1-A:lO. ARlAH. ARlAO
Complete Items C3a-i below according to the building diagram specified in Item C2. State .the darum used. If t1e datum is different from
the datum used for the BPE in Section B convert the datum to that used forthe'eF:. Show fie!d measurements and datum conve",'on
'calcUlation. Use the space provided or the Comments area oi Section D or Sedion G. as appropriate. to cocumen! the datum o:mve",ion.
Datum 'oC010'2."1 Conve",ionlComments <::'~p ;:<!CV~Y'iiL
EI9€'~on re.ierence mark uselt~t7,.. JC,r.,~ Dces the ele'r.nion reierem:"marx used a~pearon the FIRM? U Yes Jkl No
ref Jil'f lOp 01 bottom flooc Qnduoing basement or encosure) c:; I Z ,tz.. i".(1') 'li
~b) Top oinexthignerflccr 51'S. ,..Lft.(I:'l)::; r REGISTERED "-
o .f) Bottom oi lowest horizontal struc:'~rai member IY zones cnly) 'u, 4, _ it( ~ ~ PROFESSIONAL
g' 9l Attached garage (top of slab) z:; /2> . fJ.... 1\.( ~ 11 LANJ) SURVEVOFi
rff .; ~~:~;i~~;e;:~:~i~i~;acilinery anClcr equipment .5 / &, ..Q fl.(,) ~ i' /0 ~ a /ff
€:( j) Lowest adjacent grade (LA,G) ,'512- . J... 1\.( ~ l OREGON'-' j
~p( ~ H' , ,. c; i '2cJ2-fl ( ) ~.. JULY 20,1993
- .Igne:t aCjacent grade (HAG) ," ' ,:..:;<..,' "';; REXA BE1Z
I<( bl' No. cr permanent openings (i1cec vems) within 1 iI. aoove aOjacant grace _ "'\ /I?!;Ofl ,
.:(i)' Total area oi all permanent openings (flocd vents) in C3h . C; 01./.. sq. in. (~) C:Yr.> I zJ 31/ CJ:S
SECTION D - SURVEYOR. ENGINEER, OR ARCHITECT CERTIFICATION
This certirication is to be signed and sealed by a land surveyor, engineer, Oi orc:hitec: aLrthcrized by law to cerJfy elevation information.
I cenify that the information in Sections A. B, and C on this certificate represents fD'/ best efforts to interpret the data available.
enderstand that anv false statement may be punishable by fine or imprisonment under 18 U.S. Code. Section 1001.
RTIFIER'S NAM~ A _ r.l J... . UCENSE NUMEER PL<" /7 / .
e~ \')&\'2- ._ _......_ ./ ~6 (p
TITLE. C I I (;UMI-'Aj~1 NP..o".~ ~(_ C'\. _ -r-J
.) U. yy e'1 AJI, 4 III '? 'C' (v CITY 1')'( a.1 ~ _!::- """" I ,;.., ~ Gy ""'" ..1--Ct.c, ,
ADDRESS 3\n -:S,..Ft-l,.. S\v--e,./,f' , __'50{'\""'1 h'C\"'t~AI"orZ ZIPCOOEd7l.f-7'7
SIGNATURE ~o/.. -a. /;7~' ..JlA,e '2 ~/'O/'1a 'eL:PHON9_ '\ ' . ')
.. <'.;?.<I' .. 7t.vv--P '{1. t:,-",-, <-- (~i.{l ) 7'1-GrD0 J 7
. .",. _.....~
~=,\.lA l='1"\"""'" R1.;1 ^,.rr-.--;:;;; -. ro""~ r"'\"" 1~.f"'CC cIne: t:'()Q rn...r.-"\III.'.,...I......~1 n.......... . ___ ... _ _ _. '. ..
IMPORTANT: In these spaces. eopy th.sponding information from See~on A. ,
6UILDI~G STRE"T ADD~ (Incuding Api" Unit. Suite, and/or 61Cg. No,) OR P.O. ROUTe AND 60X NO.
. (0 /4 ~ ~\..fL-'. '" I.~ 1= /. V'l ~ _ ..
CITY r .. STATE Z:t-1 CODE
"S O("\Y"\C,il-clJ ()J'Z Chll77
I Fer Insurance Company Use:
PoliC'f Numcer
C.:mpany NAIC Numce!
.
SECTION D.. SURVEYOR. ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate fcr (1) communiiy offical. (2) insurance agenUcompany, and (3) building owner.
:>:\(:co~~lf~T,s of C;P'-;'V,<' 'b:e\l) Bc"V\~'" )JuvL ~el"',,\ c, cl\\ \e.leA """"'.L.<.4Ve. (I'<-L+ l~ -tk
, r r r.l.::' r' .t::.
-Thl' ~Lde.., t".N Ct..O'-h <,t -\'1...17 W\iJ?Cl\',t ,.r ('-'....i-? ,-c::.ll.l.('h ",7 -t~ <;oLctlt..;ed CO(\UY 0.1
(,7tL, CW\d nu,,,.~t(lY\ \->::III""-!:, aYl elc:va.tio..... (!J.f 51'2..,..f;;\ <2.,:'n-! O"tt..""" I'J-",dt:<d;v<.h(
~ e(e-vt-ntV\ '71::3.1\ A}(:.Vr)'l,,! \.VbS u<,t:) a<, w.~"suS",feIBVAhti\o1<, trev~o"'.
U Check here ii attachments
SECTION E - 8UILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and ZONE A (WlTHOIJT 8FE)
For Zone AO and Zone A (without 8FE). complete Items E1 through E3. If the Bevation Certiiicale is intendedforuse as supporting
information for a LOMA or LOMR-F. Section C must be completed. .
E1. Building Diagram Number ~ (Seled the bUJlding lfsagram most similarlD the building Iilrwhich this certificate is bei~g completed-
see pages 6 and 7. ,If no diagram accUrately represents the bwllflDg, provide a sketdl or p;_;....Q~h.)
E2. The top of the bottom'floor [lDc!I,zding basement or enclosure) of the building is LU ft.(m) LUin.(cn) U above or.. U below
(check one) the highest adjaCent grade.
E3. For Zone AO only: If no flood depth number is aV3Jlable, is the top of the bottom floor eIeYated in Q_.';",.cewith the community's
floodolain management c;~~~,,~? I, I Yes I J No LI uriknown. The Iccat oflicial must certify this ~.;~,,_~"" in section G.
, : SECTION F _ PROPERlY-OWNER (OR OWNER'S REPRESENTATIVE) CERTIACATION
The property owner or owner's authorized represen1ative who completes Sections A. B,and E fer Zone A (without a FEMA-issued or
community-issued BFE) or Zone AO ri1ust sign here. '
ADDRESS
<.;1.1
SlATE
ZIP CODE
.
PROPERTY OWNER'S OR OWNER'SAUTHORIZED REPRESENTATIVE:':; NAMe
SIGNATURE
DA.::
i EtEPHONE
COMMENTS
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 floodplain management ordinance can c:::lmpie!s
Sections A. 8. C (or Ej. and G of this Elevation Certificate. Complete the applicabie itemis) and sign beiow.
G'i. U The information in Section C was taken irom othercdcCJmentaticn that has"be<"'..!l signed and embossed by a licensed surve'lor,
engineer. or architectwno"is auttlonzed by Slate or lccallaw to certify eievaticn iniolUICUcn. (Indicate the SCl.rrcs and date ~i the
e!e~ation data in the CommentS area below.)
G2. U A community offidal compieted Section E fer a buiiding lcc:zted in Zane A (YlithClIt a Fa1J1.-issued cr c::mmunity-issuec E:==) cr
Zone AO.
G3. L! The foilowing information (Items G+G~) is proviced fer ~r:1mur:ity ticcd~iain management pu~cses.
I, G4. FERj\'lIT NUMEE~ I G3. DAIt: FE::\MIT ISSUcC ; \.:0. O~~ ;:~;;-;;;C;;':I~ OF COMFLlANCEiCCCUPANCY
11<::-::: n=:"'",
! -----
G7. This permit has been issued f~~ U N~w CcnstrucJcn U Subs;:anriai Im!=rovemem
Ga. Elevation of as-built lowest floor ~nc::uding basement) oi me buiiding is:
G9. EF" or 0n Zone AO) depth of flceding at the building site is:
LOCAL OFFICIAL'S NAME
. _ ft.(m) Datum:
'_ ft.(m) Datum:
TIi"t.=
COMMUNITY NAME
j-C:i?HONE
SiGNATURE
DATe
.
COMMENTS
I I Check hele if attachments
....-..- ....--.......... ...,...........
REPlA(~F~ All PRFYIOUS EDITIONS