HomeMy WebLinkAboutMiscellaneous APPLICANT 12/13/2010
, U:S'. DEPARTMENT OF HOMELAND SECURle
Federal Emergency Management Agency
National Flood Insurance Program Important: Read the instructions on pages 1-9.
ELEVATION CERTIFICA"
OMS No. 1660-0008
Expires March 31, 2012
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SECTION A. PROPERTY INFORMATION : For Jhsuranc~.Coiripa:ny"Use:,. :':~:::'. "-'
A1. Building Owner's Name Mike and Alisa Deller , . POljcy.~ury1b~r:- "..:', ,",...., '.: ,: . " , ',c,:::
.',- ," ' <,,' '. ., ..
1'.2. Building Slreel Address (including Apt., Unil, Suile, and/or Bldg. No.) or P.O. Route and Box No. Company,NAIC Num~er ' ,,,
2763 N 21" Street . '~" ", ~ ".-~. -. .
'. "
City Springfield Slale OR ZIP Code 97478
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
LollS, 2nd Addmon to Et Bontta Gardens Map 17-03-24,42 Lot #2728
A4. Building Use (e,g., Residential, Non-Residential, Addition, Accessory, etc.) Residental =:ceiVed'
AS. Latitude/Longitude: Lat. 44.07539 Long, 122.99341 Horizonlal Datum: 0 NAO 1927 [8] NAD 19 ' DK
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. '
A7. Building Diagram Number ~
AS. For a bunding with a crawlspace or enclosure(s):
a) Square footage of crawlspace or enclosure(s)
b} No. of permanent flood openings in the crawlspace or
enclosure(s) within 1.0 foot above adjacent grade
c) Talal nel area of flood openings in A8.b
d) Engineered flood openings? 0 Yes [8] No
o
1.11Q
sq II
A9, For a building with an attached garage:
a) Square footage of attached garage 2.ll SQ ft
b) No. of permanent flood openings in the attaChed garage
within 1.0 foot above adjacent grade Q
c) Tolal nel area of flood openings in A9.b Q
d) Engineered flood openings? 0 Yes
sqin
[8] No
2
691
sqin
I B 1. NFIP Community Name & Community Number
Lane County, Unicorporaled Areas - 415591
SECTION B. FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B4. Map/Panel Number B5. Suffix BS, FIRM Index B7. FIRM Panel B8. Flood B9 Base Flood Elevallon(s) (Zone
41039C-1153 F Date Effective/Revised Date Zone(s) AO, use base flood depth)
June 2, 1999 June 2, 1999 AE 452.44
B2. County Name
Lane
B3. State
OR
B10. Indicate the source ot the Base Flood Elevalion (BFE) dala or base flood deplh entered in Item 89.
o FIS Profile 0 FIRM [8] Community Delermlned 0 Other (Describe) _
B11. IndicateelevationdalumusedforBFEinllemB9: [8] NGVD1929 0 NAVD1988 0 Ofher(Describe)_
B12. Is the building localed in a Coeslal Barrier Resources Syslem (CBRS) area or Otherwise Protected Area (OPA)? 0 Yes
Designation Dale _ 0 CBRS 0 OPA
t2I No
SECTION C. BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
o
Finished Construction
C1. Building elevations are based on: I:8i Construction Drawings. 0 Building Under Construction.
"A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARiA, ARiAE, ARIA1-A30, ARiAH, ARiAO. Complele Items C2.a.h
below according to the building diagram specified in Ilem A7. Use the same datum as the BFE.
Benchmark Utilized See Comment Vertical Datum 1929
Conversioh/Comments Citv of SDrinafield Bench at 2933 Yolanda Dublished bench _ 459.60'
a)
b)
c)
d)
e)
Top of the next higher floor
Bottom of the lowest horizontal structural member (V Zones only)
Attached garage (lop at slab)
Lowest elevation of machinery or equipment servicing the building
(Describe type of equipment and location In Comments)
Lowest adjacent (finished) grade next to building (LAG)
Highest adjacent (finished) grade next 10 building (HAG)
lowest adjacent grade at lowest elevation of deck or stairs, including
structural support
451.p'
o/a._
450.Z
450.Z
Check the measurement used.
[8] feel 0 meters (Puerto Rico only)
r2.1 feet 0 meters (Puerto Rico only)
o feel 0 meters (Puerto Rico only)
[8] feet 0 meters (Puerto Rico only)
[8] feet 0 meters (Puerto Rico only)
Top at bottom noor (Including basement, crawlspece, or enclosure fiaor) 449.Z
f)
g)
h)
450.Z
~.~
450.Z
[8] feel 0 meters (Puerto Rico only)
[8] feel 0 meters (Puerto Rico only)
[8] feet 0 meters (Puerto Rico only)
SECTION 0 . SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification Is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certity elevation
information. J certify that the information on this Certificate. represents my best efforts to interp;et the data avaHabJe.J
understand that any fatsa statement may be punishabte by fine or imprisonment under 18 U.S. Code, Section 1001,[8]
Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a
licensed land surveyor? [8] Yes 0 No
/
_____ r
Address 90686 Northrop Drive
City Eugene
Slale OR
ZIP Code 97402
PROFESSIDNA
lANDSURVEYO
W d.:W.!
OREGON
JULY 1985
DAVID H. WELL
2163
Certifier's Name David Wellman
License Number OR' PLS 2163
Tille President
Company Name D. Wellman Surveying
Date 12/1012010
Telephone 541-984-1442
RENEWAL: 6f1l>/tl...
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IMPORTANT: In these spaces, copy t
Building Street Address (including Apt., Unit, S
2763 N 21" Street
City SpringfieldState OR ZIP Code 97478
rresponding infonnation from Section A.
, andlor Bldg. No.) or P.O. Route and Box No.
".Fo/:hl,surari'ce' C:~rrip.anY"Use,:~: "~:,':.):;.':
CompanyNAIC. Number.
SECTION D . SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agentlcompany, and (3) building owner.
Comments A5 - Determined with GPS on site.
B9 - Elevation received by Springfield Planning.
C2 (a) - Addition crawlspace level indicated on plan,s is same as measured at residence at same elevation.
C2 (b) . Exialing residence living floor elevation. Addition floor level as indicated on plans dated 10/27/2010 to be 1.58' higher at elevation 453.5 feet.
C2 (e) - Hot water heater, furnace, and laundry on garage slab.
-
Signature ~ ... / / J Ill! . Date 12Jl212010
.....J ~ />'. e-.J effti--- IiiJ Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)
.......-,
."-".
.-, ,,:.,.
For Zones AO and A (withoutBFE), complete Items El.E5. If the Certificate is intended to support a LaMA or LOMR-F request, complete Sections A, B,
and C. For Items E1-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters.
E1. Provide elevation information for the fOllowing and check the appropriate boxes to show whether the elevation is above or below the highest adjacent
grade (HAG) and tha lowest adjacent grade (LAG).
a) Top of bottom floor (inciuding basement, crawlspace, or enclosure) is _'_ 0 feet 0 mete", 0 above or 0 below the HAG.
b) Top of bottom floor (including basement, crawlspace, or enclosure) is _'_ 0 feet 0 meters 0 above or 0 below the LAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A lIems 8 andlor 9 (see pages 8.9 of Instructions), the next higher floor
(elevation C2.b in the diagrams) of the building is _'_ 0 teet 0 meters 0 above or 0 below the HAG.
E3. Attached garage (top of slab) is _'_ 0 feet 0 meters 0 above or 0 below the HAG.
E4. Top of platform of mach!nery and/or equipment servicing the building is _'_ 0 feet 0 meters 0 abolle or 0 below the HAG.
E5. 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 management
ordinance? 0 Ves 0 No 0 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, e, and E for Zone A (without a FEMA~issued or community-issued BFE)
or Zone AD must sign here. The statements in Sections A, B, and E are correct to the best of my knOWledge.
Property Owner's or Owner's Authorized Representative's Name
Address
City
Stete
ZIP Code
Signature
Date
Telephone
Comments
n Check here If attachments
G2.D
G3..D
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. Check. the measurement used in Items G8 and G9. .,:.
G 1. 0 T.he information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who
is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.)
A communtty official completed Section E for a bUilding located in Zone A (without a FEMA-issued or community-issued 8FE) or Zone AD.
The following information (!tems G4-G9) is provided for community floodplain management purposes.
G4. Permtt Number
G5. Date Permtt Issued
G6. Date Certificate Of Compliance/Occupancy Issued
G7. This permit has been issued for: .0 New Construction 0 Substantial Improvement
G8. Elevation of as-buill lowest floor (including basement) of the building: _'_ 0 feet 0 meters (PR) Datum _
G9. BFE or (in Zone AO) depth of flooding at the building stte: _ _ 0 feet 0 meters (PR) Datum _
Gl0. Community's design flood elevation _ _ 0 feet 0 meters (PR) Datum _
,'.
Local Official's Name
Title
Community Name
Telephone
Signature
Date
Comments
o Check here If attachments
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For Insurance Company Use:
Building Street Address (including Apt., Unrt, Suite, andlor Bldg. No.) or PO. Route and Box No. Policy Number
2763 N 21" Street
I City Springfield State OR ZIP Code 97478 Company NAlC Number
If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to
the instructions for Item A6. Identify all photographs with: date taken; "Front View" and "Rear view"; and, if required, "Right
Side View" and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page,
following.
Building Photographs
See Instructions for Item A6.
Front View -1211012010
Rear View -12/10/2010
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