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Home My WebLink AboutFEMA Application 1999-6-2 FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ,ELEVATION CERTIFICATE OM B No 3067-0077 Expires July 31, 2002 ,f Important Read the instruction!) on pa~es 1 - 7 SECTION A - PROPERTY OWNER INFORMATION ~ For Insurance Company Use Policy Number BUILDING OWNER S NAME -tOM u:.HIi2h co 2:,-, MovAe-s BUILDING STREET ADDRESS (Including Apt , Unit, SUite, and/or Bldg No) OR P 0 ROUTE AND BO~ NO 0eo, ~ PN7? CllY STATE , n -0P~I~'Fl~ OQ.. PROPERlY DESCRIPTION (Lot and Block Numbers Tax Parcel Number, Legal DescnptJon, etc ) u.:rr 41 ~(~~l% 2,u~ ~b\T\Ot-..! Fllk- 16 . ~ll)c~ IlS"L - L~SS lA1Jc..COUl-LI\' BUILDING USE (e g ,ResldentJal Non-resldentJal, AddltJon, Accessory etc Use a Comments area, If necessary) \2.E:? i \) b..J.. 1\ A>- LATITUDE/LONGITUDE (OPTIONAL) ( ##" _ ## _ ## ##" or ## #####0) Company NAIC Number ZIP CODE cn4-1<E? Pc.A-1- \2k:L~bS HORIZONTAL DATUM LI NAD 1927 LI NAD 1983 SOURCE I_I GPS (Type) LI USGS Quad Map I_I Other ~ECTlo.~ B~~LO()D INSURANCE RATE MAP (FIRM) INFORMATION I B1 NFIP COMMUNllY NAME & COMMUNllY NUMBER I B2 COUNlY NAME B3 STATE -,??l2..f...1UF-\ E~ 41 'S~C(~ LkuE..- DQk.Qot...l B4 MAP AND PANEL B5 SUFFIX ' B6 FIRM INDEX B7 FIRM PANEL B8 FLOOD B9 BASE FLOOD ELEVATION(S) NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO, use depth of flooding) 4-\b~c.-ll(O~ +=- 0 2..-ct'1 (P'"2.-<q.., Y:.. ..{; Af!- 51~ ~ B 1 0 Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered In B9 I_I FIS Profile '--' FIRM ,lS-Communlty Determined I_I Other (Descnbe) B 11 Indicate the elevation datum used for t 1e BFE In B9 1__1 NGVD 1929 1_-' NA VD 1988 1..)5/.other (Descnbe) ~ B12 Is the bUilding located In a Coasta/Bamer Resources System (CBRS) area or Otherwise Protected Area (OPA)? I_I Yes 1;61 No DeSignation Date _ SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1 BUilding elevations are based on '--'Construction Drawlngs* I-I BUilding Under Constructlon* ~lnlshed Construction *A new Elevation Certificate Will be required when construction of the bUilding IS complete C2 Building Diagram Number z.. (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 A 1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA. ARlAE, ARIA 1-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 calculation Use the space provided or the Comments area of Section D or Section G, as appropnate, to document the datum conversion Datum \..cx..~ Conversion/Comments -- Elevation reference mark used ~ CDM..iIA~1""") Does the elevation reference mark used appe on theJt~~~1:. t;f.1liXfS-? If$~ o a) Top of bottom floor (including basement or enclosure) C3l~ ~_ ftft ~)) ~ aNl1- ~u.f~V2YOR I. o b) Top of next higher floor S n (\.... v o c) Bottom of lowest hOrizontal structural member (V zones only) HI ^ ft (m) ::: 2 . .~ o d) Attached garage (top of slab) -:71<.::0 _~_ ft (Ja) j i ~ I... 1.1 I ~ o e) Lowest elevation of machinery and/or eqUipment .: '" ~~ A,-- "- servicing the bUilding (Descnbe In a Comments area) 5" L(.., (p ft (...) ~::;..,.. . ",---1__.......'. -- "'" E ro OReGON, ; o f) Lowest adjacent (finished) grade (LAG) 511,:> _L_ ft 4&1) ~ ~ Jli'l" 1~. 1\j;U , o g) Highest adjacent (finished) grade (HAG) 5\10:1 _L ft~) ~ rn "\. JONATtifl,N A. OfJ<ES } o h) No of permanent openings (flood vents) Within 1 ft above adjacent grade l3 ~ " . . A'1~ . ~-:' o I) Total area of all permanent openrngs (flood vents) In C3 h I (P1~ sq In ~) I'!...,L",~' D~::?;;.<. 2(:1:J'2'.- . SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION ThiS certification IS to be signed and sealed by a land surveyor, engineer, or architect authonzed by law to certify elevation Information .) / certify that the mformatlon m SectIOns A, 8, and C on thiS certificate represents my best efforts to mterpret the data aV81/ab/e , understand that any false statement may be pUnishable by fine or Imprisonment under 18 U S Code, SectIOn 1001 :RTIFIER'S NAME , A Ilfl. . _ LICENSE NUMBER -.JatJ.~ -~.... ~ L'7." 2..-10'5' TITLE ~Otv1PANY NAME .peer';:.:.r -lD).J.A:c.- ~ ~e.AJ,e-(De- fOA4~ ~d f.-LuJU~ {S~c."(tr-J.€' \t--LL. ADDRESS -P ~ I::l... "'- .... ,,.-,.,. CllY STATE ZIP CODE ..Q ,.......0.. c-t::l W4 ~L 0'f2- ~l 4aZ-- SIGNATURE _ \.....,..11 . n (\ DATE TELEPHONE ~ ~~ c::::r I~ 0'2- 5~ -4es -~~<;; ~FMA~nrmR1-~1 1111 nn o;;F~ RF\lFRo;;F O;;lnF FOR rONTINllATION RE"PI ArFO;; AI I PRF\lIOllo;; FnlTlONo;; IMPORTANT In these spaces, copy the correspondmg mformatlon from Section A BUILDING STREET ADDRESS (Including Apt , Unit SUite and/or Bldg No) OR PO ROUTE AND BOX NO ((-,COol M.D~ PA"7"-=> rv STATE ZIP CODE Company NAIC Number C?P \2.1~ h. ~v.I) 0f2- q141~ 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 0-1, i\ Of ~P~II.4(fFI f:..t..\) ~lA IAA"a-Ii- ~?vQ.l. ~ M A C--tt1 ~E<..-~ ?QuA-0€- I t-l -nti:... mp m:: ~ ~ k'r nT€.- MlDPOlr--L-r ()~ ~ GI..J<2-b e-e..~ fr=rt1tce-? \cJ, ~'4-Ic€AL D~ ~ lJ-lree..~IION (JC (O~"J: * ~&7IDJ.-l. e.D ~t.e". 'bl"Z-.'D\ '-_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 E1 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) 1__1 above or I_I below (check one) the highest adjacent grade (Use natural graoe, 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 nighest 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, 8, C, and E are correct to the best of my know/edqe PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME . For Insurance Company Use Policy Number JRESS 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 of this 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, engln~er, or architect who IS authOrized by state or local law to certify elevation information (Indicate the source and date of the eleyatlon data m the Comments area below) G2 I_I A community offiCial c9mpleted Section E for a bUilding located In Zone A (Without a FEMA-Issued or communitY-Issued BFE) or Zone AO G3 I_I The follov:,lng mformatlon (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 L-I New Construction I_I Substantial Improvement G8 Elevation of as-bUilt lowest floor (mcludmg basement) of the bUIlding IS G9 BFE or (In Zone AO) depth of f100dmg at the building site IS LOCAL OFFICIAL'S NAME __ ft (m) Datum _ ft (m)Datum TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE r'"'~4MENTS 1__1 Check here If attachments. 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