HomeMy WebLinkAboutFEMA Application 1999-6-2
.......................-
"
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
OM 8 No 3067-0077
ExpIres July 31, 2002
Important: Read the instructIons on pdges 1 ~ 7
SECTION A - PROPERTY OWNER INFORMATION
BUILDING OWNEQ S NAME"",? (\. .1 t . .. -... --
,.-,ruKOlJ ~
BUI~L,DING STRE=T ADDRESS (Inc!udrng Apt UmfSUlte andior 81Cg No) OR PO ROUTe AND SOX NO
h'd93 ::S1Jv16o/J Dj(IUc::.
-CITYS~y -h ~\d STOK.
p~OPE;Qyy D~~PTION (latand Block NumoelS, Tax Parcel Numcer Legal Desc::ptlon, etc.)
\..-Dt- '11 Lev \ l6l11d(V\~ 1",,& /\~/.l~ ~
BUILDING USE (e/g , Re,rloe'luai, Non-resIOe'lOal Addlbon, A=ssory e!C. Use CommenlS sec:ron If necessary )
1?e-s (d~ *Q ~ \
LA TfTUDEilONGITUOE (OPTIONAl) hORIZONTAL:JA TUM SOURCe U G?S (Type)
( ##0 - ##' - ## #:#" or ## ####tfj U NAn 1927 U NAD 1983 U USGS Quad Map
1 For Insurance Company Use
PoliC'1 Numbe'
Comoany NAIC Numoer
ZIP COOS
q 7tt78
U ather
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1 NFIP COMftlUNITY NAME & COMMUNITY NUMBER ' B2 COUNTY NAM~ _ t 53 STA~ .0
Ct~ od- Sp-r""''1f1dJ 415;;12-- La",p LL)u",- ... LJ~
84 MAP AND PANEL B5 SUFFIX B6 FiRM INDEX B7 FiRM PANEL B8 FLOOD 89 BASE flOOD ELEVATJON(S)
NUMBER DATE EFF.:-C'TIVE1REVISED DATE ZONE(S) (Zone AO, use depth of flooding)
L\lo~qc..\\to(p F :rlvv\t2,,11qo::r~t, t1-1Cf ~ 5/3;-8
810 IndIcate the source of the Base Aood Bevation (BFE) data or base flood depth entered U1 B9
U FIS Profile ~RM U Commuruty Detenmned U Other (Describe).
Bl1 Indicate the elevation datum used for the BFE In 89 Q(NGVD 1929 U NAVO 1988 U Other (Descnoe) _
B 12 Is the bUilding located In a Coastal Barner Resources System (C8RS) area or OthefWlSe Protected JVea (OPA)? U Yes jz9.No
DeSIgnation Date
ADDRESS
SECTION C - BUILDING ElEVATION INFORMATION (SURVEY REQUIRED)
BUIlding elevations are based on: UConstrucuon DraWings. U8uiIding Under Constructon" Finrshed ConstrudJon
. A new Elevation Certificate "!Ill be reqUIred when ........,u Lldlon of the building IS compJet.e.
C2 BUIldIng Diagram Number f? 0 (Select the budding dIagram most Similar to the bullolllgfor whIch thIS cemiicate IS being comolerea _ see
pages 6 and 7 If no diagram accurately represents the buddtng, proVIde a sketcn or photograCh )
C3 ElevatlOns - Zones A 1-A30, AE, AH, A (WIth BFE), VE V1-V30, V (with BFE), AR, ARiA, ARiAE ARiA P'3Q ARJAH P.RJAO
Complete Items C3a-1 below accordmg to the budaIng OIagram soecriied In Item C2. Slae the catum usee IT ..'Ie Dalum IS mTIe'e'lr iTCi;"'
the datum used for the 8FE In Section B, convert the datum to that used for the 8F::.. Show fiele me:::suremerns ana aa!l1m converslcn
calculation Use ,the space proVIded or the Comments area or Secuon 0 or SectIon G, as aoorocnate to CCcume'lr the oalum c:::nverslor
Datum N6IJp Z1 Convers.on/Comments
ElevatIon rererence marK usedY- ?c.c. ~fC-1 ~ . Does the e'evanon reTf:re'J~ ~rx useo aOD€ar en the F.RM? ~ Yes M No
Cl a) Top or bottom rloor (lneuDlng oase'11e'lr or e'lcosure) 5/cj 12.... ft (m) ci _
o b) Too or next hlOner rlecr 5/7 .3 rUm) :-:
~_' ) AOttdUn+ot-:.:... =~, I.~, .....~...c:.J -'u ......,.... "" ....C"IlCC C/ zel-'''''':' ~.'"f;) 5/ / _ -::;- ~( 1 j: .. ~EG'Sr~~~-.. ...'\
G acnea garage (too or slao) Ie ~ h ml ~ IIl"'/II'!IOFESS4t)~AlL
o e) Lowesl e1evallon or macnmery arruor ea~lcmerl :: UND SUIRVEYtHi '
servlc ng the bUIIGmg S /5' k ft (m) ~ .tl ..;::..;. \ _ .dOO?...;"'" __
o f) Lowest aClacent grade (LA.G I .5/5 I3- ft (m) ~ ~:..---Yvu; "",. r..a~ _
o c) hlCnest aClacent oraae (hAG) 5 J b ..L ft (m) ~ 1 ,=~oo . v' OREGON ... .0_--;
- - - - JULY 1 ~
:J h)_No or pe'1Tlanent ocenrngs (flcca Ve'lls) wlln10 1 ft :cove aOlacent grace 12-.. ~ GARy L ~~R ~
o I) J otal area or all permanent openrngs (tloao Ve'lls) 10 l..3h t:Jbf.o so In ~Q C':") ~~.o_ ..__~"'--_)
SECTION D - SURVEYOR. ENGINE.:t, OR ARCHITECT CERTIFICATION.t1c €.xf I z-! 3/ /03
T nIS certITlcallon IS to Oe signee and sea/eo oy a land surveyor, engmeer, or arcrutect authcnzed by law to ~'1IiY e1evanon lntormallcn
I cerrIty that the mrormanon m SectJo(!p A, B, and C on thIS certJficate represents my best efforts to rnterpret the data avaIlable
I understand that any false statement may be pumsnable by fine or Impnsonment under 18 US UJde Secnon 1001
--=qTIFIER S NAME..- /" / /' _ LJCENSc NUM6E::Z pc;: _
-- 6' -It'! L (.-4.1.( I~ - L:) _ _ _ ~6 5f}
-- COMPANY NAM - _
.. u.yVe I t{ Q c: e YUlt\0 _ _~l",", -(Gy ~') _ ~c
'f',f-tL., 'Srv"Q)fJ h d?{SIAJL:JrZ, ZIP CODE q 74-71
Z TELEPHON I) 71.f&-{) 0 '3 7
Irl:::
SEE REVERSE SIDE FOR CONTINUATION
FEPLJlCES AI I POt::\I'I""\"<, ~"~,,...,"~
IMPORT ANT In these spaces, copy the corresponding snfonnabon from Section A.
BUILDING STR,E~T ADDRESS (Including Apt Unit Sude and/or BJdg. No.) OR P 0 ROuTE ANO BOX NO
b~q.3 .5/~OJ-1 P!ZlvG:. - . -, -
CITY STATE LIP CODE
~ pr)-Y\~-eJJ ()1Z c;,lf,f)
. " -'
For Insurance Company Use
Pollc"! Numcer
Comoany NAIC Numcer
SECTION D _ SURVEYOR, ENGINeER. OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides Of thiS Elevation Certificate for (1) commum\y officai. (2) Insurance age'ltJcompany, and (3) bUllcJng owner
COMM~NIS f I l I
~ C' i +'1 U ~ 0(" "t-", '"' ~'c \d B ~ V\ ~ .Ala v L. 'nel'" PI ~ CII\ \ ') e e4 "S,c," ALl" e.. (I". + \ v\ -tluL..
... 1_ (l)- ' r j - .
Y\' ri-{"- eN LL" b '" t ~ ""~." t "~ (w "In <"-f",..-,,, (.f it... < ".... tl.,,,,ed CO'''' "Y of .
Cc..7 -l"k ,:""vl "" (.{ y S to", \, all"" <') "'~ de .Y'" t,'"", c:f 5 11- . g l C.. ''1 \) ~ 14", "",.J .a d J ~ < bi
~ e-(~vlLtttv\. S 19. \ \ O&VD'24 waS u<,e) a~ ~ ~uSIlS d e-1e,;AhOVl"S II,ev€olt1
U Check here If attachments
SECTION E _ BUILDING ELEVATION INFORMATION (SURVF(NOT REQUIRED) FOR ZONE AO and ZONE A (WITHOUT BFE)
For Zone AO and Zone A (Without BFE), complete Items E11tJrOU9h E3. If the ElevatJon Certrficate /.S mtended for use as supporting
mformation for a LOMA or LOMR-F, Section C must be compJeled. , --
E1 BUIlding Diagram Number - (Select the building diagJ3I11 most similar to the buikfmg for \.1.....:-. thIS certriicate IS bemg completed-
see pages 6 and 7. If no diagram acdJrately represents the building, proVIde a sketch or photograph)
E2. ThetoPOf_thebottomfloor(indUdmgbasementaren~~)ofthebuiIalngis - I I Ifl(m) I I ~n.(cn) Uaboveor_Ubelow
(check one) the highest adjacent grade. -
E3 For Zone AO only: If no flood depth number IS available, IS the top of the l.~... ftoor elevated In accordance WIth the community's
f100dplam mana-gement ofdimince? I_I Yes - U No - L) \JnlcnOWI1- Th~ offiaal must csrtJfy ttus ;..fu......L....n in Sadlon' G.
SECTION F _ PROPERTY OWNER (OR O~ER'S REPRESENTATIVE) CERTIACATlON
- -
The property owner or owner's authonzed representative who CDmpletes Sedians A. 8, and E for Zone A (WIthout a FEMA-Issued or
commumty-Issued BFE) or Zone AO must sIgn here
PROPERTY OWNER'S OR OWNER S AlJTHuKiLc.1J REPRE~--&iIAT1VE'SNAME
ADDRESS
ICfTY
STATE
ZlP CODE
DATE
1l:Ll::PHONE
SIGNATURE
1-1 ChecK here If attachments
COMMENTS
i G4 PERMIT NUMEE;::;"
\
G5 DAI t: t't:~j'l1IT ISSJEJ
_ ft.(m) Datum
_ ft.(m) Datum
TiTLE
COMMUNITY NAME
TELEPHONE
OAif
SIGNATURE
COMMENT;
1-J Check here If attachments
RePLACES ALL PREVIOUS EDITIONS
-
.-r-.....^ r:,^rrn Q.1_~1 A( I~ ~q