HomeMy WebLinkAboutFEMA Application 1999-6-2
f -"
. () \ - \ 0&
FEDERAL EMERGENCY MANAGEMENT AGENCY
NA TIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
o M 8 No 3067-0077
Expires July 31, 2002
I
Important Read the instructions on pages 1 - 7
SECTION A - PROPERTY OWNER INFORMATION
~~ ,\ .~~-L~\.. tJ~
BUILDING STREET ADDRESS (Indud'lng ~ Unrt SUIte and/or Bldg No) OR P 0 ROUTE AND BOX NO
(;;, ~ l ~^A IJ.~-f.'- S fJCl.<; <:;
CITY STATE
SOY'"IV\ et~ 0
PROPER'fYOESCR TION (lot and Block Numbers, Tax Parcel Number, Legal Oescnptlon, etc.)
L"ot q I I ~\/I I ~".... ~d A-.k{li"1t-VI "U.\c Mb~ 17-oZ-3Lf-Q
BUILDQ USE (e 9 ,Re,lderitl31 NOn-resldentlai?Addltlon, Accessory, etc. Use Comments SectJoll d necessary )
- e~h \It\.\ _ __._ . _".
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL UAI uNI SOURCE U Gt-'S (lype)
( ##Q - ##' - ## ##" or ## #####j U NAO 1927 U NAO 1983 U USGS Quad Map U Other _
BUILDING OWNER S NAME
For Insurance Company Use
Policy Number
I Company NAIC Number
llP CODE
7477
Ph.. uf'1t'\K lot 100(;
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
8.1 NFIP CqMMUNITY NAM. E & COMMUNITY NUM8ER 82 COUNTY NAME + 83 STATE A V'J
Qf~ uT S pl~~ tlGlcA 1{ t5 SCJ1.....Lal-1 e COctY\ '1. __ _ __ L/~
84 MAP AND PANEL 85 SUFFIX 86 FIRM INDEX' t:l7 FIRM PANEL t:ld t"LUUD 89 BASE FLOOD ELEVATlON(S)
NUMBER F DATE EFFECTIVElREVISEDDATE ZONE(S) (ZoneAO, use depth of floodIng)
4 I O~ q C- \I (, if ;:rIA "I l, 1'1<ft.:IL.. ",,, Z,j f'i <J )(.. A 10'" e -br- -Z""'"e X
810 Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered In Sg--{, :K. ~ Se e A-t\-4v~ Vlt.~
U FIS Profile !:)4jIRM U Commumty DetermIned U Other (DellaJbe) r1 t:. Q TP,. l~, 7.-Oa I
B11 Indicate the elevation datum used for the BFE In 89 ~GVD 1929 U NAVD 1988 U Other {Descnbe} .
B12 Is the bUilding located In a Coastal Barner Resources System (CBRS) area or OthelWl5e Protected Area (OPA)? U Yes ~No .
DeSignatIon Date
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C 1 BUilding elevations are based on UConstructJon DraWIngs. ~dding Under ConstructJOn. UFlnlshed Construction
*A new Elevation CertIficate ~I be required when construction of the buddmg IS complete
- BUilding DIagram Number 7-.f _ (Select the bUlldmg diagram most slmdar to the buddmg for which thiS certlficate IS being completed _ see
pages 6 and 7 If no diagram accurately represents the bUilding, prOVide a sketch or photograph)
C3 Elevations - Zones A 1-A30, AE, AH, A (With BFE), VE, V1-V30, V (With BFE), AR, ARiA, ARiAE, ARiA 1-A30, ARiAH, ARiAO
Complete Items C3a-1 below accordmg to the bulldmg diagram specriied 10 Item C2 State the datum used If the datum 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 D or SectIOn G, as appropnate, to document the datum conversion
Datum~?, V 0'24 ConversIon/Comments
Elevation reference mark used~ S -: P (:J.eve vSe..Does the elevatIon rererence mark used appear on th.= FIR~2.._ L' Y es ~No
~) Top of bottom floor (mdudlOg basement or endosure)15 I ~ ...2. ft (UJ) ~ J'" REGISTERt::D' \ .
~) Top of next higher floor ._5 I Lf 3- fl(~ ~ PROfESSIONAL
~) Bott".., J." Iv"",,",, l.ulL'.:~>fflu1 ~tn'M"r'" mpmhF'r (\/ zone~ only,\ _ f. \If.) ~ ~ LAND SURVEYOR
iY'd) Attached garage (top of slab) 5/3 S ft (m) ~ -g . //:;( L% _~
~e) Lowest elevation of machinery andlor equlpme'lt II B ~ : I R~ cJ. //~,
servlc:ng the bUlldmg 5 '., _ ft (Jiiy ~ ~ OREGON
cYf) Lowest adjacent grade (LAG) ...r::: I Z Cl ft ("'" ~ ~ JULY 20, 1993
B'jl) H'ghe" adJacen' g,ade (HAG) ,5 13 -L ft 1m) ; " ~~ '" /
IB" h) No of permanent opemngs (flood vents) Within 1 it above aOJacent grade /6 11' . J,
U'I) Total area of all permanent openmgs (flood vents) m C3h ----1...r' 2D sq In. ~ - L 12 Elcj? 12/;1 61
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICA TJON
ThIS certIfication is to be Signed and sealed by a land surveyor, engmeer, or architect authonzed by law to certlfy elevation Information
I certify that the mformatlOn m SectJons A, B, and C on thiS certificate represents my best efforts to mterpret the data available
I understand that any false statement may be pUnishable by fine or Impnsonment under 18 U S Code, Section 1001
CERTIFIER S NAME r"""j) --n -i-. LICENSE NUMBE~- Z
- K-r=' k: -D e-....L2--- t-L.. S & 0 (~
E S COMPANY NAME TI ( ~_
- l..A.VVCu1, MC<lAC(3eV- V rUvt 6\.-1 EhS/),-eey,\.-1.c, ~< .
. nuDRESS 3\0 _Rf-t~ Si,ree-t c~r""5 fldcl STATEO~ zIPCODrq7~77
SIGNATURE ,~O, ~ - ~< \"3, 2-06 \ TElEPHON'tS41) 7tf-ro- ()(/~ 7
FEMA Form 81-31, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PRl=Vl()llC: J::nlTlmlC'
IMPORTANT In these sp<lces, copy the corresponding ,"formation from Section A.
BUILDING STREET. ADDR SS (Including Apt U~ SUite and/or Bldg No) OR P 0 ROUTE AND BOX NO
f../? (t:? I Lf ~ e <; \\,q-<; S
CITY ::; {,; - - - - STATE f( ZIP CODE
pr e'0 (J y2't7/
>0/ ,
For Insurance Company Use
Policy Number
Company NAIC Number
1
SECTION D _ SURVEYOR. ENGINEER. OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both Sides of this Elevation Certificate for (1) community offiCIal, (2) Insurance agent/company, and (3) bulldmg owner
~~"!\.; of ~ p n....... f';' \d R&l<lr,~ ,tAl' f he, "? '" c/... .s.deJ s 1uuve (1... t w-. -tt.....Dp
~ / <' ,1 C'..,.x k, ~ -\1^<1 "'" .."tl" '" ",t- "" ~J ""t.. ,,- ~ :h.. ... ~ ..... f 1-kIt <; p t.< -tt, cue<. -t- (' -" v>o. e" of'
~~ ~\l....:~v-5+~~"~"'5 6V'~VA.'h~4 .sr2.81 C:1v. 'it.tu-, W
a ~ -h, t>1,."" i1 w. 5/3. J I )l b v D '2.<1 UJu <. L!.Y'.,(" <. 12..~, <; .J' 12 kv <<TltM. <;;.
->It. -* ') ee- '" -ttu"l.eJ ~ T""",,""""'-T. J.je.l 'Qe<e..-r>bv I, . ~ I l!:1Check here Jf 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 E1 through E3 If the BevatJon Cerl1ficate IS mtended for use as supporong
mformation for a LOMA or LOMR-F, SectIon C must be completed
E 1 BUIlding Diagram Number (Select the budding diagram most Slmdar to the bUilding for which thIS certificate IS being completed-
see pages 6 and 7 If no diagram accurately represents the budding, proVIde a sketch or photograph)
E2 The top of the bottom floor Oncludlng basement or endosure) of the bUilding IS 'I I. fl(m) , I 1m (em) U above or U below
(check one) the hIghest adjacent grade
E3 For Zone AO only If no flood depth number IS available, IS the top of the bottom floor elevated In accordanceW1th the commumty's
f100dplam management ordinance? I I Yes LI No LI Unknown The localoffiaa\ must certJfy thIS U1formabon In Secbon G
SECTION F _ PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTlACATlON
The property owner or owner's authonzed representative who completes Secbons A, B. and E for Zone A (W1thout a FEMA-ISSued or
community-Issued BFE) or Zone AD must sIgn here
PROP~KTi OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAMf
DATE
STATE
TELEPHONE
ZIP CODE
CITY
ADDRESS
SIGNATURE
COMMENi;
I~ Check here If attachments
SECTION G _ COMMUNITY INFORMATION (OPTIONAL)
The local offiCial who IS authonzed by law or ordmance to administer the communrty's floodplain management ordinance can complete
SectIons A, B, C (or E), and G of thIS ElevatJon Certificate Complete the appltcable rtem(s) and SIgn below
G 1 U The information 10 SectIon C was taken from other documentatJon that has been signed and embossed by a licensed surveyor,
engineer, or architect who IS authonzed by state or local law to certrfy elevatlOn information (IndIcate the source and date of the
elevation data In the Comments area below)
G2 U A community offiCial completed SectIon E for a budding located In Zone A (WIthout a FEMA-Issued or community-Issued BFE) or
Zone AO
G3 U The followmg mformatlon (Items G4-G9) IS prOVided for community floodplain management purposes
- - - - -- - - .
G4 PERMIT NUMBER G5 DATE PERMIT ISSUED Gb UA II: CeRTIFICATE OF COMPLIANCEJOCCUPANCY
ISSUED
G7 ThiS permit has been Issued for U New ConstructIon U SubstantIal Improvement
G8 Elevation of as-bUilt lowest floor Ondudlng basement) of the budding IS
G9 BFE or (In Zone AO) depth of flooding at the building site IS
LOCAL OFFICIAL'S NAME
_ fl(m) Datum
_ fl (m) Datum
III Ll:
i"fLEDHONE
COMMUNITY NAME
SIGNA lUKE
DATE
COMMENl5
l~ Check here If attachments
REPLACES ALL PREVIOUS EDITIONS