HomeMy WebLinkAboutFEMA Application 1999-6-2
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FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
o M B No 3067-0077
Expires July 31, 2002
Important: Read the instructions on pages 1 - 7
.... SECTION A -1A\PRqPERTY OWNER INFORMATION
BUILDING OWNEQ S NAME ""' '"- ~
, ,,-.:)~ ~.A11~
BUILDING STRE=T ADDRESS (Inc'udmg Apt Unit. Suite and/or Bldg No) OR P 0 ROUTE AND BOX NO
q Lf rz- (t?(oi-~ '? \ Cl { -e...
C'TYsOYVv-Af ~\d STolZ
Pf\Op~q7Y DESCRlPTION (Lot and Block NumoelS Tax Parcel Numoer. L~al Desc.--rptJon, er.c.)
\-.D"t- 71 LevI l4vv.J1"'~ Z''''~(~~~ .
8UILDING uSE (e g , Re,rlcentlal, Non-residential, AdtIibon. Aa::e:ssory. e!c. Use Comments sec:Illn ri necessary )
"Res Cdl~ +Q ~ \ _.__
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DAtUM SOURCE U G?S (Type)
( ##0 - ## _ ## #:f' or ## ~ U HAD 1927 U NAD 1983 U USGS Quad Map
For Insurance Company Use
PohC'j Numcer
Company NAIC Numcer
ZlP COD~
07'17/
U Other
SECTION 8 - FLOOD INSURANCE RATE MAP CARlI) INFORMA nON
81 NFIP COM~UNITY NAME & COMMUNITY NUMBER 82. COUNTY NAM71_ t _ _83 STA~ ,0
C~~ oJ 'SfY~~Fdd '417;:;12.- La'1P LOUV\, ~ L.)""-,
B4 MAP AND PANEL B5 SUFFIX B6 ARM INDEX B7 FIRM PANEL 88 FLOOD
NUMBER DATE crl""cCTJVEIREVISED DA;rE ZONJ;(S)
L\IO'1qc...\ \~(P -F ~ :Ti.u..,,:Z,,'i1q:r~ t\ ~'f~q- X
810 Indicate the source ~f the Base Flood- Be\...r...... (BFE) data or base flood depth e...;,:.....J III 89
U FIS Profile ~IRM - _ U Commuruty Detennined U Other (Desaibe):
811 Indicate the elevation darum used for the 8FE m 89: Q(NGVD 1929 U NAVD 1988 U Other (Descnbe).
812 Is the building located In a Coastal8amer Resources System (C8RS) area or Otheswise Protected Area (OPA)? U Yes ~o
DeSignatIon Date
89. BASE FLOOD ELEVA TlON(S)
- (Zone AO, use depth of flooding)
No\') e.. de.. S Ie, h tt kd .
SECTION C - BUILDING ElEVATION INFORMATION.!SURVEY REQUIRED)
, 8U1ldlng elevations are based on. UConstrudlOn OraWII1gs* UBuildmg UnderConstrudlon* OOFimshed Construdlon
* A new Elevation Certificate ~u, be requIred when .....~.JdIon of the buddmg IS compfe!e. -
C2 8U1ldlng Diagram Number Pi. (Select the bL,:E.,,,, diagram most sundar to the bt.:':'-:t for whIch thIS certIficate IS being completed _ see
pages 6 and 7 If no diagram accurately represents the budding, proVIde a sketch or ~....~graph )
C3 ElevatIons - Zones A 1-A30,-AE, AH, A (wrth 8Ft), VE. V1-V30, V (wrth BFE),-AR. ARiA, ARiAE, ARiA 1-A30. AR/AH, AR/AO
Complete Items C3a-1 below accordmg to the budding magram specriied m Item C2. Slate the datum used If the oarum IS omere'1r ITem
the datum used for the BFE m Section 8, convert the datum to that used for the BF:.. Show fie'd measurements and datum convers.on
calculation Use the space proVided or the Comments area of Section 0 or Section G. as aporopnate, to Document the Datum conversion
Datum ~&VO . 2Cl Conversion/Comments
E7vaoon reTerence mark used ..y <;.ee Q e\I e,,< e... Does the elevanon rerereru::e marx used aooear on the FIRM? U Yes Ii! No .
IH }l) Top of bottom floor (Inducmg basement or enClosure) !) I I 5 ft.( ) ~
f3' b ) Top OT next hlgner floor . &) I 4 2. ft.( ) i CD ( REGISTERED "
:::: /) ::...a", " '" L."...w;;..!:w"7Mbl ctpJCUNiI m'iffiSer r' zcp-.. ,",r.J;:} _ft.( ) ~ ~ PROfESSION. AL ..
c:r d) Attachea garage (top of slab) - S 13 2> ft.( 8] ~D SURVEYOR ,
IJ/'e) Lowest elevation or machmery and/or enUlcme'1r -?. _ ] ~ //- /J'(; .. ../____ .
, / servlc:ng the buIlding r.;; 13 ..>L.. it ( ) E ro /0f.:--y;- Wt /~re;
Ej f) Lowest adjacent grade (LA.G) 5 I Z L ft.( ) ~ E l OREGON
c:( g) Highest aOJacent grade (HAG) 5 13 !::L it ( 1 ~.:: JULY 20, 1993
e- }1) No or permanent opemngs (flooo vents) Wlthm 1 tt aoove aOlacent graoe I. I ~ R~1::1 L.. ,/
151) Total area of all permanent opemngs (flood vents) In C3h q '2. t.f sa. 10.. (sq. em) --i...:.J ( e/ t? Ll::I3/ /01
SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
Tms certificatIon IS to be SIgned and sealed by a land surveyor, engmeer, or architect authonzed by law to certIfy elevation mformatIon
I certify that the infOrmatIOn In Sections A, B, and C on thiS certJficate represents my best efforts to mterpret the data available
I understand that any false statement may be DUnIshable by fine or Impnsonment under 18 U S Cade, Section 1001
-=qTIF1ER S NAME..r--, f\ r.J eX UCENSE NUMtit:R.p C
Ke~ - I~~ \'J "2..- ___.___. L::/ '2b6 (0
-j-L'" .' l.,UMt"ANY NAM~ .
I I - S u. yV e'1 U a. "'\ ? '1 e,-y __ "Or alA, d.1. Bt.-:; I y., -e ~ ~j ~:Rt.c
ADDRESS 3\0 '"f\,ft~ 'Sh-~ ~1:l:_S -IvY"> hdvi:~AT~rZ ZIPCODE?J71.f7t
SIGNATURE ~ /J /7. -I- UAIt: P J ~I::LEPHONe;,."\
~ C~ /~~ .Tc..l-\.lAuv-1 11/2vD:j (5'-1.1) 7lf&-{)(P 3 7
Fi:::V1A Form 81-31, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT In these spaces, c;pythe corresponding information from Section A-
BUILDING STRE::T ADDRESS (Inc'udln~pt Unit SUIte, and/or BJdg No) OR P 0 ROUTE ANU tiui NO
q 4 tz.. & "-r~ Y \blt <"" ..-
CITf r . - - - - STATE l'P CODE
"S f> r \-1"\ '7 -rr-c(, 4 (') 'fZ q f If -;"7
I For Insurance Company Use
Pollej Number
C..mpany NAIC Numce'
SECTION D .. SURVEYOR, ENGINEER, OR ARCHI~<r~ CERTIACAnq,~ (CONTINUED)
Copy both sides 01 this ElevatIOn Certificate for (1) commumty oTfic:al, (2) Insurance ag~'ltlc:JmcanyJ and (3) bUllolng owner
COM!'-'1!=-NTS .c: [) . r. )J' I , I' - ! ..
* c \..,+'1 U-J r '"':JP(,""'j .1\c. \d 'BeV\~ ~~VIL- \.-.el~1 ~ C,^) )e\~ ~'::'!1.A-4V e. (',.(..L+ 1'-" t~
---\-r,'f1 fL~t'e... OJ Cuy-b G..t -tlt.z W\l&9D1\.tt D1 (',-.n"'~ lGfU.("h (iT -\-~ ,)i/LLtltl.0ed CO{I1e-v- of
~_3-t~ CW\d n:~~ vstr,,^ ~~'.~l'~ a~ eleva.tL~ C!.),f 51'2... g \ C \.\~ 0 ,,-R""'- o""d b.d J ~ <, tt..(
-to e(c\!unt1.A. .c; 1::3.l \ ,o&VD'2Q witS u.<:,e) a<;) ~ Q,uSIlS J-" e-levAhows ~,eyeovt
. U 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 ~3 If the BevatJon ~i";'_te IS mtended for use as supportIng
mformatJon for a LOMA or LOMR-F, Section C must be completed.
E1 BUIlding Diagram Number - (Select the buikflng diaQiam mOst similar to the building for which this certriicate IS beIng completed-
see pages 6 and 7 If no diagram acdJrately represents the building, provtde a sketch or photograph.) , .
E2. The top of the bottom floor Ondudmg basement or endosure) of the budding is - ,I I , ft..(m) I I hn.(an) 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 accordance WIth the community's
floodplain manaqement ordinance? I I Yes I j No U Unknown. The local offiaal must ""V.f thIS U1fo........on In Seeton G. -
. SECTION F _ PROP~I {OWNER (OR OWNER'S REPRESENTATIVE) CERTIACATION
The property owner or owner's authonzed representative who completes Se..l:....., A. 8, and E for Zone A (without a FEMA-Issued or
community-Issued BFE) or Zone AD must sign here.
PROPERTY OWNER S OR OWNER'S AUTHORIZED REPRESENTATJVE'~ NAAi~
5TATE
ZlP CODE
ADDRESS
l,ll T
SIGNATURE
COMMENTS
OAlc
'rELEPHONE.
, 1-1 Checi< here If at"..achme'1ts
SECTION G :COMMUNITY,INFORMA1l0N (OPTIONAL)
Tne local offiCIal wno IS authonzed by law or ordInance to adl11lmster the comrrnmrty's flooaclam management CfOInance can ccmClere
SectIOns A, S, C (or E), and G of thIS ElevatIon Certriicate Complete the aocllc:aoie Item{s) and Slgn below
G 1 U The InrormatJon In Sectlon C was taken from other documentatIon that has bee'l Slgne!J ana emcossed by a licensed surveyor,
engIneer, or archItect wno IS authonzed by s-.ate or local law to certrry ele'JatJon Information (InOleate the source ana aate of me
elevation data In the Comments area below)
G2 U A communrry offiCial complered Secnon E for a burlOfng locate!! In Zone A (WIthout a FE..MA-lssued or ccmmunlt'{-Issued EF::) or
Zone AO
G3 U The follOWing infOrmatIOn (Items G4-G9) IS proVIded lor c:Jr:1mumtv flocomam manageme'lT OU!1:oses
I G4 PERMIT NUMBER G5 DATE PERMIT ISSUE] ! Go UAfE C~=liFICATE CF COMPLIANCE-OCCUPANCY
I I ISSuE:J
G7 Tms permit nas been Issued for LJ New Cons1ruC'Jon U Substannallmoroverne'lt
G8 ElevatIon of as-bUIlt lowest floor 0ndudmg basement) ot the buuomg IS
G9 8FE or (In Zone AO) depth of floodmg at the bUlldmg sIte IS
LOCAL OFFICIAL'S NAME
_ fUm) DaTUm
_ fl(m) Datum
TITLE
COMMUNITY NAME
TELE."'HONE
SIGNATURE
CAfE
COMMENTS
I Check here If attachments -
REPLACES ALL PREVIOUS EDITIONS -:..n;
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FEMA Form 81-31, AUG 99