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Home My WebLink AboutFEMA Application 2002-7-31 I ' '~iKc-:;j F/LE- tt 02-001/5 -0/'- . . ,I ' 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 - PROPERTY OWNER INFORMATION BUILDING OWNER'S NAME ~ Mitt p"TO jIJ. . " ' , BUILDING STREriADDRESS (1nclud~g Apt., Unit, Suite, andlor,Bldg. No.) O~ P.O. ROUTEAND BOX NO. , . ~'l'" M lZt>tJ ~E- ' ," CITY STATE., ZIP CODE ~~\2.IM~t=,-ec..i:) .. Ot2- , uc:f7411 ' PROPERTY DESCRIPTION (Lot and !:lJock Numbe~ Tax Parccl Number, Legal Description. etc.) , LOr \0; u:."\t...~I-LD' Z..,.~[)" -,0,.J ~L.E..'"S' 1..IDE.:"::>ll i..:" - UTMe:. '~p~P-e('WC~ BUILDING' USE (e.g., r<esidential. Non-residential. Addition, Act:;essOry, etc. U e Comments section if necessary.) ~":>\ D~\ I-rl- . ' LA TlTUDElLONG/TUDE (OPTIONAL) HORIZONTAl. OA TUM: SOURCE: U GPS (Type): ( #if.#if _##.##" or ##.#####') U NAD 1921 ,U NAD 1983 U USGS Quad Map U Other. I 81. NFIP COMMUN~TY NAME&. COMMUNITY NUMBER 82. COUNTY NAME' , -?'t=' 12-1 r--14 F I ~ '- Q' 41 S c:a:12 ' C-A1-1-E- 84. MAP AND PANEL. B5. SUFFIX 86. FIRM INDEX, B7. FIRM PANEL B8. FLOOD, NUMBER ' DATE, , EFFECTIVElREVlSeo DATE ZONE(S) 4 \ 0 ~~ c:-1I1.4(" , "f ' ~. 2. 'Gl,"'"\ C' '=' . "2....q~ . :c-o t>:-"f2. "" 610. Indicate the source of the Sase Flood 8evation (8FE) data or base,tlood d~ entered in 89. U FIS p.rOfile U FIRM. . ~ Community Determined U Other (Desciibe): 811.lndicate'the elevation datum used for the 8FE iIi 89~ NGVD 1929, U NAVD 1988 U Other (Descnbe): ' 812. Is the building located in a Coastal8arrier Resources System (CSRS) area or Otherwise Protected Area (~PA)? U Yes , ~ignation Date: ' " ' SECTION 8'. FLOOD INSURANCE RATE MAP (FIRM) INFORM81:lQt{,., B3.STATE ~e:.oN 69. BASE FLOOO EL.EVATION(S) (Zone AO; use dePth of flooding) . Sr2..4 UNo.' 'SECTION C _ 8UiLDlNG ELEVAT10N INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: UConstruction Drawings.' ' M8uilding Under Construction- UFinished Construction "A new Elevation Certiticate will be required when construction of the building is complete. . . C2. 8uildingDiagram 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 A1-A30, AE. AH. A (with 8FE), VE, V1-V30. V (with 8FE), ARt ARiA. APJAE. ARiA 1-A30,ARiAH. AFJAO '. ' Complete ItemsC3a-i below alX6rdingto the building diagram specifi~in Item C2. State the datum used. If the datum,isdiff;erentJrom the datum used for the BFE in Section 8. convert the datum to that used for the SFE. Show field measurements and datum conversion' , calculation. Use the space provided or the Comments area of Section Dor SectionG, as appropriate, to document the datUm Conversion. Datum tJ:Ic.~ Conversion/Comments ADt:> o.~''TD ~ DA-lUM to ~'F.e.,..{J~. 6#i'V,,^ , " Eleyation. reference mark used~.JZ.. Q)MM~""tlI'; Does the el,evation reference marl< used a~pe7U1e.!;~~~ 1:.1. ~: ~o ,,' Q a) Top of bo~om floor Qncludlng basement or endosure) ,C; \'? " dr ft.(8If< i 'Pll.OUOSj~AL 'l' , ,Q b) Top of next higher floor , . C,\I,O ,..E..ft.-.): : L~NE SU~YOR Q c) 80ttom of lowest horizontal strudural member rv zones onlY) N J A . _ ft.(m) ! ~ ".,. , .,.. .."...,':..", Q ~ Attached garage (top oh~ab) '5 { ~ ,.:.J2. ft.) ~ 1 ,\.., fa A' r; .' /1 Q e) Lowest elevation of machinery andlbr equipment =- f .J~ L ~ servicing the building luCDM.9l.izTE- . _ ft.(m) ~ - ,g . ~ ,., .. ,r . = :! 0 OREGOfil . Q 1) Lowest adjacent grade (LA.G) , 1I..u:':m<<A.P ~ . _ ft.(m) % ~' . JU.'t1~'984: ' Q g) Highest adjacent grade. (HAG) j ULO'l\I1.~ .' _ ft.(m) , i " ,.JONATiiANJ. OAKES I Q h) No,. of permanent openmgs (flood vents) within 1 It. above adjacent grade' n ~.... " .. " "H' ... , , ,. ., Q ij Total area of aUpermanerit openings (flood vents) in C3h . 1G\27i sq. in. ,:~"1!l). , b:IUIc c ~ ? (u:oz,. SECTION. 0 _ SURVEYOR, ENGINEER; OR ARCHITECT CERTIFICAT10N. . . This -...;ll;f.cation is' to be ~igned and sealed by a lan~ surveyor, 'engineer, or architect authorized by law to certify elevation information. / 0 ' that the information in Sections A, S, and C on this certifICate represeilts my best efforts to interpret the data avaiable. , ,I unaerstand that any false statement may be punishable by fine or imprisonment under 18 U. S. Code, Section 1001. CERTIFIER'S NAME \ ,^' ""'A ,:.. ' UCENSE NUMBER , , -....J Q~I'\-~ J+. ~~ ol2.-E- L'7.~ 2\ 05, TITLE '. COMPANY NAME ' ~J2.~e~IO~ ~ ~E.:'(OYZ. ~~E.. ~1"""e.F-A..1.~J. ~""~,(~. ADDRESS CITY' stAre' ZlP cooe ;p.o. ~ z.,S"2-t :Clv",~,"I.~. ~ . ~,407' , ,^ -. /,' CArt-'- ~~H9~~ .",.....~" -- IMPORTANT: In these spaces, copy the corresponding Infonnat/on from Section A. BUILDING STREET ADDRESS (Including Apt, Unit, SUite, and/or BIdg. No.) OR P.O. Rou-rf ~~~ BOX NO. (d.()qr., ~ ~ CITY STATE ZIP COOE ?P/2.1 ~ ~ ~~ 0Y2- 9.'14-n SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) ; Copy both sides of this Elevation Certificate for (1) community officlal, (2) Insurance agentlcoj:l'lpany, and (3) building owner. COMMENTS " ur-f OF ~P2..c 1-l(..1=t.lU..'" ~ A4~ ~~ ~ A G6+t~r-t...i:-l;;;. ~ ~ Wo-i. ~ ",p ~ I*E ~ kr~ M,.bPo,loJ".\ ~ ~ c:..d2-~ ~~ ~ ~ ";)"-" c.oa.~ ~ ~ u..l.1'f:4,~~'1"l.~ ~ ~-,l)j:- 4- ~\l",",,' ~. CAT"( PA=i'UM c:,l"2..!>\ ~~ .000001JM .$,\~.\ ~,y:rl Ol--l '5~\l..L1J. ~i. ~ (.b)o.l,\lE:.ll.~ 1l> 1=-:.e-. M. ,A , DA-t-U rf\ 1-1 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 E 1. through E4. If the Elevation Certificate Is intended for use as supporting Information for a LOMA or LOMR-F, Section C must be completed. E 1. Building Diagram Number (Serect the building diagram most similar to the building for which this certificate is being completed - ..s~e_P!9!5 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) E2. The top of the bottom floor Oncluding baSementorenclosure)ofthe building'ls r I -, ft.[m) CI-liii(cm), 1-1 above or 1-1 below (check one) the highest adjacent grade. (Use natural grade, 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 I-L-I ft.(m) I-L_lin.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i on 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 f1oodplai'n manaQement ordinance? '-..) Yes I_I No I_I Unknown. The local official must certifv this information in Section G. SECTION F. PROPERTY OWNER (OR OWNER'S REPRESENT AWE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A. B, C (Items C3.h and 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, B, C, and E are correct to the best of m'( knowledr;e. ' ' PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ~Fcr. riiSlifciffc:e,r."JVn""rRi~Usii:~.: -.' ~~'~~"'_;r', - _.-:.....-~~~..A.:~~ SIGNATURE CITY DATE STATE ZIP COPE ADDRESS TELEPHONE COMtll1C'l1 ~ Ll 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 C~rtificate. Complete the applicable item(s) and sign below. G 1. 1-1 The information in Section C was taken from other documentation that has' been signed and embossed by a licensed surveyor, '". engineer, or architect who is authorized ~y'state or local law to certify elevation Informaticn. (Indicate the source and date of the , ,elew.tlondat:al in the Comments area below.) . G2. L:.:.JI\"&>mn:Junity .officlal cpmpleted Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or : ,., 'ZoneAO. ,'". G3. '1-1 The following information (Items G4-G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER I G5. DATE PERMIT ISSUED I G6. DATE CERTIFICATE OF COMPWANCElOCCUPANCY , ISSUED G7. This perm~ haS been issued for: 1-1 New Construction I_I Substantial Improvement Ga. Elevation of as-b~i1t low~stfloor,Oncluding basement) of the building is: G9. BFE or (In ZoneAO) depth of flooding at the building site is: . , ..',.',... .". . LOCAL OFFiCIAl'S NAME . _ ft.(m) Datum: . . _ ft.(m) Datum: TITLE COMMUNI1Y NAME SIGNATURE TELEPHONE DATE COMMENTS I_I Check here if attachments ~~UA Fnrm R1~~1 .1111 nn R~PI Ar:~!=: AI I PR~lnll!=: ~nlTlnN!=: