The URL can be used to link to this page

Home My WebLink AboutFEMA Application 2002-6-19 ~ FEDERAL EMERGENCY MANAGEMENT AGENCY NA TJONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE Im~ortant Read the instructions on paQes 1 - 7 SECTION A - PROPERTY OWNER INFORMATION BUILDING OWNER'S NAME _ 1) l:; "-3 t-J li? t.. 0 \J \i (2. \ BUILDING STREET ADDRESS (Including Apt, Unit, SUite, and/or Bldg No) OR P 0 ROUTE AND BOX NO Q'1 0 ~-rf4 Pv~~ CITY STATE S 'P (2...1 NLc.I=', ti L" () 012.. PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal DescnptJon, etc) BUILDING USE (e 9 , ResldentJal, Non-resldentJal, Addition, Accessory, etc Use a Comments area, If necessary ) ~~'''~r1AL' LATITUDElLONGITUDE (OPTIONAL) HORIZONTAL DATUM SOURCE LI GPS (Type) ( #If'. ##' - ## t#f' or ## #####") LI NAO 1927 LI NAD 1983 LI USGS Quad Map o M B No 3067-0077 Expires July 31,2002 "Ff>r<rnsuran~ CompajlY Use.. "PoliCY Number ~ 11 b~" ~ , \<1 lj,f~<)rl l.'lll k:l"" l ~~..j 11' l l'* i Co?1pany NAlC Number ~ I "" h ZIP CODE ,. LI Other SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1 NFIP COMMUNITY NAME & COMMUNITY NUMBER B2 COUNTY NAME B3 STATE B4 MAP AND PANEL NUMBER B8 FLOOD ZONE(S) B5 SUFFIX B6 FIRM INDEX B7 FIRM PANEL DATE EFFECTIVElREVISED DATE B9 BASE FLOOD ELEVATION(S) (Zone AO. use depth of flooding) t:"::> \ 0.. I B 1 0 Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered In B9 1-1 FIS Profile 1-1 FIRM I~I Community Determined I_I Other (Descnbe) B 11 Indicate the elevatIon datum used for the BFE In B9 I~I NGVD 1929 I_I NA VD 1988 I_I Other (Descnbe) B12 Is the bUilding located In a Coastal Barner Resources System (CBRS) area or Otherwise Protected Area (OPA)? I_I Yes L-I No DeSIgnation Date SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1 BUilding elevabons are based on 1_IConstructlon Drawlngs* 1_IBUlldlng Under Constructlon* ~IFlnlshed Construction *A new Elevation Certificate Will be reqUired when construction of the bUilding IS complete C2 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) C3 Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1.V30, V (With BFE), AR. ARIA, ARlAE, ARlA1-A30. ARlAH, ARlAO Complete Items C3 a-I below according to the bUilding diagram speCified In 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 calculabon Use the space prOVided or the Comments area of Section D or Section G. as appropnate, to document the datum conversion Datum Conversion/Comments _ _ Elevation reference mark used....!2}t) ,s,~ Does the elevatIon reference mark used appear o~~iBRll~~ I~ No o a) Top of bottom floor (including basement or enclosure) ':> \ '::> tl (m) l . / ~~.~~\; \ N ~~~ o b) Top of next higher floor __ ft (m) ~ '{f;j ~ ~L\ ~ o c) Bottom of lowest honzontal structural member (V zones only) _ ft (m) ~ ~ 4; LiB 2~~'" ~ o d) Attached garage (top of slab) '=>11 1l. ft (m) ~ -g ( 00 /I J1 '" . o e) Lowest elevation of machinery and/or eqUipment W. .. /' ~CA/,,\ '-_ servicing the bUilding (DeSCribe In a Comments area ) ~ 11 ~ ft (m) ~ ~. ~ OREGON & Of)Lowestadjacent(finrshed)grade(LAG) '=>11 &..f> ft(m) ~~~~ ~U-4RY'S,~(S ~oVJ o g) HIghest adjacent (finrshed) grade (HAG) ~ L l Uft (m) ~ ~ ~~:1''1/ o h) No of permanent openmgs (flood vents) Within 1 ft above adjacent grade -L'; .3 'II S, 'n\.\~ 10 z.. o I) Total area of all permanent openrngs (flood vents) m C3 h I 2... '"'l ~ sq In (sq cm) -SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICA ,f~flIRA-iioN DIU l: !j~~.~/ () ~-r ThIS certification IS to be Signed and sealed by a land surveyor, engmeer, or architect authOrized by law to certify elevation information I certify that the informatIOn In SectIons A, B, and C on thIS certIficate represents my best efforts to Interpret the data avaIlable / understand that any false statement may be pUnishable by fine or Impnsonment under 18 U S Code, SectIon 1001 CERTIFI~l.Zt~~ t?, \..h~,..j2.0JV1 LICENSE NUMBER S/.ff) Z2 _ p,; , ITLE COMPANY NAME LA_ EI1(, \1\ ~ETl2- I wt2=\' Late. &1"1'"-''76"612-1'1 ~ ADDRESS l'2>-l&j p~~ ~ e.B~E'~ iJt:..E ZIPEf..1j~oJ SIGNATURE DATE TELW: If f) if - 'Ie f,o I=I=MA I=nrm R1_~1 1111 00 ~I=I= RI=\lI=R~1= ~Inl= I=nR rnl\lTll\IllATlnl\l RI=PI Arl=~ All PRI=\llnll~ I=nlTlnl\l~ .., IMPORTANT In these spaces, copy the correspondmg mformatlon from Section A. BUILDING STREET ADDRESS (Including Apt , Unit, Suite, anellor Bldg No) OR P 0 ROUTE AND BOX NO For lnsu.rance Company Use' ~ ~poficy Numberw.~ ,,'~ ~- ' '>'>0 >,,>' \"..) 1>>~ II :,,It.; Jl ;rh bo.", CrTY STATE ZIP CODE '.Co~m~:~ ~~N~mqer: ,,-, 1,...",j "'" Y\ l(~.... It, j;/ ~ ... 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) bUilding owner COMMENTS '-_I 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 E1 through E4 If the Elevation Certificate 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 floor (including basement or enclosure) of the bUilding IS 1_1_1 ft (m) 1_1_11n (cm) I_I above or I_I 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 floor or elevated floor (elevation b) of the bUilding IS 1_1_1 ft (m) 1_1_11n (cm) above the highest adjacent grade Complete Items C3 hand C3 Ion front of form E4 For Zone AO only If no flood depth number IS available, IS the top of the bottom floor elevated In accordance With the community's floodplain manaQement ordinance? I_I Yes I_I No I_I Unknown The local officIal must certify thIs Information In Section G SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATiVe) CERTIFICATION The property owner or owner's authOrized representative who completes Sections A, B, C (Items C3 hand C3 I 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, S, C, and E are correct to the best of my knowledfle PRO....I:tl.1 '( OWNER'S OR OWNER'S AUTHORIZED RE....tl.I:;:,ENTATIVE.S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE 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 floodplain management ordinance can complete Sections A. B, C (or E), and G ofthls Elevation Certificate Complete the applicable Item(s) and sign below G1 I_I The information In Section C was taken from other documentation that has been Signed and embossed by a licensed surveyor, engineer, or architect who IS authOrized by state or local law to certify elevation information (Indicate the source and date of the elevation data In the Comments area below) G2 I_I A community offiCial completed Section E for a building located In Zone A (Without a FEMA-Issued or communitY-Issued BFE) or Zone AO G3 I_I The follOWing information (Items G4-G9) IS prOVided for community floodplain management purposes G4 PERMIT NUMBER I G5 DATE PERMIT ISSUED I G6 DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7 ThiS permit has been Issued for I_I New Construction I_I Substantial Improvement G8 Elevation of as-built lowest floor (including basement) of the building IS G9 BFE or (In Zone AO) depth of flooding at the bUilding site IS LOCAL OFFICIAL'S NAME __ ft (m) Datum _ ft (m) Datum TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS '-_I Check here If attachments I=I=MA I=nrm R1_'H 1111 nn RI=PI Arl=C: AI I PRI=VI()IIC: I=nlTl()t\lc: