HomeMy WebLinkAboutFEMA Application 1999-6-2
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FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTJFJCATE
OM 8 No 3067-0077
EXDlres July 31, 2002
Important. Read the instructIons on p..ges 1 - j
SECTION A - PROPEqTY OWNER INFORMATION
BUILDING OWNEQ S NAME .~. .. <( I U - _
~ \\ ~ vA....uJU U^'"'.J
BUILDING STRE:: I ADDRESS (Indudll1g Apt Umt SUite and/or 81cg No) OR PO ROUTE...1.'lD SOX NO
(c74.>1 Ta('nl-:, LaV\ e
CITYS(JY~ ~ <::\4 - ST'3r:z.
P~OFE{~1Y DESCRlPTION (Lot and Bloc:'t Numcers Tax Parcel Numt;e'. Legal OesC'lpucn. e!C.)
W, <:P \ '--ev \ Lti,lMilV\~ '2l1\d MA ~ ~ .
BUILDING USE (e 9 , Re,rlcenllal, Non-resloentlal, Ad<lIDon, Accessory, e~c.. Use Commentssacon II ne",,:-:-:ry )
?e-s ld~ -h c<. \
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL uj\! LlM SOUR~ U G?S (Type)
( ##0 - ##' - ## ##" or ## ####:f) U NAD 1927 U NAO 1983 U USGS Quad Map
I For Insurance Company Use
POIIC! Numcer
I,
<Ampany NAIC Numcer
ZIP COD.-S
o 7tf77
U Other
SECTION B - FLOOD INSURANCE RArE MAP (ARM) INFORMA lION
B1 NFIP COM~UNITY NAME & COMMUNITY NUMBER 82. COUNTY NAM?J _ I _83 STA~ 10
<>.. \-t; ot S.f'l'v\~ 0e\4 4\ 5 ~1 z... La"\P LL)U"", Tv L..J I"...
84 MAP AND PANEL 85. SUFFIX 86 FIRM INDEX 87 RRM PANEL E8_ FLuuu 89 BASE FLOOD ElEVATlON(S)
NUMBER DATE EFFECTIVEIREVISEODA1'E ZONE(S) (Zone AO, use depth cffloodmg)
LiIO'1qC-\\~(p F Ju,'V\t'Z1I11Q :J~tl t,qq AE !:?J3.5
810. IndIcate the source of the Base Flood Bevabon (BFE) data or base flood dep1h entererlln B9-
U FIS Profile ~IRM U Commumty Oetermined U Other (Descnbe).
811 Indicate the elevatIon datum used for the 8FE In B9 ~NGVD 1929 U NAVD 1988 U Other (OesolOe)
812 Is the bUilding located In a Coastal Barner Resources System (CaRS) area orOthel'WlSe Protected Area (OPA)?, U Yes ~o
, DeSignatIOn Date
SECTION C - BUILDING ELEVATION 1~~OR~~ON.(SURVEY REQUIRED)
\.J 1 BUilding elevations are based on UConstruClJon DraWlngs* ~8uilding Under Construchon* UF.mshed ConsJUcnon
"A new ElevatIon CertlficategJ' be reqUired woen ccnstruchon of the buddmg IS ..........Jete..
C2 BUilding Diagram Numoer (Seled the bullolng diagram most Stmllar to the builaing for wnlCl1 thIS cel1l'ficate IS bemg comoleIed _ see
pages 6 and 7 If no diagram accurately reoresents the buildIng, prOVlce a sketct or photcgraoh )
C3 ElevatIons - Zones A1-A30, AE, AH, A (WIth BFE), VE V1-V30, V (WIIh 6FE), AR.ARJA., AFUM:, ARlA1-P.30, P.RJAH, ARJAO
Complete Items C3a-1 below accofClng to the bUllomg olagram soecriiea In Item C2. Stae the oarum used If tne catum IS ome'e'1t rror.J
the datum used for the BFE In Secnon B, convert the datum to that usea fcrthe EFE.. Show field measurements and datum convers.on
calculation Use the space proVIded or the Comments area or SeCtIon D or Secnen G, as aooroonate, to cccume'1t the cramm convers.on
Datum O(OVO 12<1 Conversion/Comments <:::',;0<7 I<!.cyeV~
El~~on rererence marJ< used~ tl '" J C Y) ti....- Does the elevanon reTflre!"a marx_usee aocear on the FIRM? LI Yes .k No "
ef Jl? : op aT bottom floor Oncuomg basement or e'1cosure) -5/ Z Ie.... ~(1) ~ . I
i!1' b) lOp or next hlgner ilccr _5/ is -L iUl'"'l) ~ /" REGISTERED 'I
= ;:) Bohom or lowest honzontal struauraJ meIT'oer (V zones onlY) ;() J ~ _ ~L.( ~ ~ PROFESSIONAL
~ Attachee garage (too or slab) c; 1.2 _ .f.:L;: ( ) E ~ LAN.J> SURVEYOR
e) Lowest e'evatIon OT maC1Inery ana/or eCUllJment .51/ () .. _~ ~_ //:/:; ./.J /; L.L..l
. ./ se"'VIC ng the buudlno l.:7 _ II ( ) ;/I'../~ w;, r r
€1 f) Lowest adlacont orac~ (LAG) 512- I ft ( ) ~ ~ OREGON--"
if .9-) hlonest aCla~en; crace (h;lG) C) / .;s:J2- IT (.) ~ -~ JRUEXlY A.20, 1993
('f,) ~ ~ 2i ~t: J .L
~ No ar oermanent aoemngs (ficoa vents) wlthn 1 ft aoove aOlace'1t grace _ ~ \ #2.enp .I
- I) Total area of all permanemopemI"gs (flccd ve'1ts) In C3h .C:oL{.. SO.Ul. (~) cyp /2/Jllo:s
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICAT10N
..-- . .
Tms certification IS to be s.gned and sealed by a lane surveyor, engIneer, or arctlltectal.rtrcnzed by law to cer"ufy elevation lni'ormatlan
I cemfy that the mrormatIon m Sections A, B, and C on thiS certJficate reDresents my cest efforts to mteroret the data available
mderstand that any false statement may be pumsnable by fine or Impnscnment under 18 U S OJde, Sect JOn 1001
=.TIFIER S NAM~ f\ r,) ~ UCENSE NUME~~ n c
K e)G /-; ~ \"J&\""2-- I' l;:) '206 (0
TITLE: ' CUrvli-'A~Y NAME.---, .,
Su.yyey Ua.Vi a c:, ey OY"ttll\d.A ~t yo, {'~ ~J ~L'
ADDRESS 3\0 F,-ft~ <S1Y~r CliY "So{" ~~t, h c L:,{ST~_J~rZ ZIP CODE 4 71.f7 7
SIGNATURE It.~ U, /E5~ c-f'~.1 ZR, .1&'0'2-- TElEDHONr-S-VIJ7tf&_0037
t==;\,fA ~f"\rrn R1_'1.1 ^II~ r"'\('"' ("'.-.- !'""lr-\,r-[""'C'C: cIne c:no rfl"-r-I"'-III"Tff"'H.1
Z'P CODE
a/Ift--;
.
I For Insurance Company Use
I Pohc/ Numcer
I C.::moany NAIC Numce'
IMPORTANT In these spa~es, copy the correspondmg InformatJo,n from SectIon A
BUILDIt'iG STRE=T ADDRF"'" (Inc'udmg"Apt Unit SUite and/or 81dg No) O~ P Q KUUTE AND BOX NO
Co /4 (j), c L~J r:o h 1_6 V1 .e
Cirf . - ('
"S or)Y\ Co, -n'Cld
,
STATE:
QfZ
SECTION 0 _ SURVEYOR, ENGINE:R, OR ;';RCHITECT CERTIFICATION (CONTINUED)
Copy both Sides Of thiS Ele'latlon Certificate for (1) community orfical. (2) Insurance age'ltlcomoany, and (3) bUllomg owner
, COMME1\JTS .c () C )Jl \ . I \ (
* l' i t( U-l -? pI" ,,-Yo: ~ pOC \d "B r' V\ L.h lI.a V \L.- 'reI'" 1 C, ell\. \ ~ e ~ ~.c-/',A.4. v e. (l A...-L+ ,'^ -tk~
Th~l ftJe... ~J. CUrb ~t ..y~~. W\ld.f?DI'vtt ,."J; (/....l ;'I--J l~:fu.Y-n ( I -\-kt <) i/L<..t4t.t:ed C.O{\1 C"y- of
Cz.....7fk CVvI.d ~Ufst(,,,\ k~v~_~' ~'" ele'v'a.t~o'" cJi 51?.. g, c: 1~\~-Y ~-R.IM. DV',,d c.d J v <, rt..(
<to e(~vt.. ntv\' 513\ \ \ A)t..,yD'Zq waS U.<;e:L( a<;. ~ ~4SIlS vS e-leVAhclV1"'S ~reyeov,
, I
U Check here If attachments
S ECTIO N E . B UI LDING ELEVATION INFORMATION (SURVEY NOT REQUIREDt FOR ZONE AO and ZONE A (WITHOUT BFE)
For Zone AO and Zone A (WIthout 8FE>, complete Items E1 through E3. If the Bevabon Ce.L.:....te IS Intended for use as supporbng
mformabon for a LOMA or LOMR-F, Section C must be camp/etedo
E1 BUIlding Diagram Number (Select the buildIng diagram most slmrlarto the building for whICh thIS certrlicate 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 (mdudmg basement or endosure) of the buildIng IS J I I ft.(m) , I lin.(cm) U above or U below
(check. one) the highest acfjacent 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
f100dclaln manaqement c. .:llnance? , , Yes' I ,No U Unknown. The local...;;:....,} must certify this information In Secbon G
- SECTION F _ PROPt:t\J {OWNER (OR OWNER'S REPRES~ATJVE) CERTlACATION
The property owner or owner's authonzed representabve who completes SectIons A. 8, and E fur Zone A (WIthout a FEMA-lssued or
community-Issued BFE) or Zone AO must SIgn here
PROPERTY OWNER'S OR OWNER S AUTHORlLt:1J KJ::r-RESENTATIVE"S NAMl::
ADDRESS
Cilr"
~AI"E
ZlP CODE
DATE
TELEPHONE
SIGNATURE
COMMENTS
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
Tne local orficlal wno IS authonzed by law or ormnance to admInister the commumw's noocclam manage'1"'e'1t ormnance can comOle,e
SectIons A. S, C (or E), and G of thIS Ele'/atJon Certriicate Comolete the aOOllcaOle rte'l1(s} ana SIgn be'ow
G 1 U Tne InTOrmatlon In SectIon C was taken from other oocumentanon that has been slgnea ana emcossea by a hce'lsea SUlVe'lOr,
engineer, or architect wno IS authonzeo bv state or Iccallaw to certl1v elevanon llTICluldllon (InmC3te the source ana cate or tne
e'e'latIon data In the Commerns area below)
G2 U A communitY offiCIal COmOle!ed SeClcn E fer a bUllolng Iccareo 10 Lore A (wnhout a F?A.A-lssuea or c:::rr.munrr'l-ISSuec E~ cr
Zone AO
G3 U Tne fOllOWing InTOrmaUOn (hems G.i-G9) IS oroVlceo Tor cornmt:mrl ficcaClam manageTe'1t cur"cases
i G.1 FSqMIT NUMBE::), I G5 DAlt:: P::=i.J\1I1 155L::] I Go C;AT~ C2~,F,CATE CF COMFLlANCE.CCCUPANC'-
\ ISSU=:J
G7 Tnrs perrmt nas Oee'11SSUeC Tor LJ New Ccns!ruC-Jon LJ SuosranDat lmcroveme'"r
G8 Ele'latlon OT as-bUilt lowest floor Gnc:udlng basement) Of the bUllolng IS
G9 6FE or (10 Zone AO) deptn or ficcOlng at the Durlomg site IS
LOCAL OFFICIAL'S NAME
1-1 Chec~ here If attachmentS
_ ft(m) Datum
_ ft (m) Datum
lilLf
COMMUNITY NAME
"f"ELE';hONE
SiGNATURE
UAll:
COMMENTS
'-_I Checl( here If attachments ,
REPLAC'FC:: AI I PR8JIOUS EDITIONS