HomeMy WebLinkAboutFEMA Application 2002-6-28
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'::DERAL EMERGENCY MANAGEMENT I 'ICY
NA TJONAL FLOOD INSURANCE PROGkAl!,'
ELEVATION CERTIFICATE
O.M.B. No. 3067..()On
Expires July 31, 2002
BUILDING OWNER'S NAME
Important: Read the instructions on pages 1 - 7.
SECTION A - PROPERTY OWNER INFORMATION
1 For Insurance C"mpany Use:
POiicj Number
BUILDING STRE::T ADDRESS (Induding Apt, Unit. Suite, and/or SIr-g. No.) OR P.O. ROUTE AND SOX NO.
{o73 '7 AQyOV\ La\(J~
CITY - . - STAI~
SOY"~~~\4 ,uK..
PfOP~R1Y ~SCR1PTION (Lot and Block Numbers, Tax Parcel Nurm:er, Loogal Desciplion. erc.)
\.-D, VJq Levi L4l<~I~t1 Z,-,/J M/i~~ '.
BUILDING USE (e.g., Re~identiaT.Non-residenlial, ~ition, Aci:assory, erc. Use Coolrnents sedan ii neo!SSary.)
1?es Cd'6\,,:i"~Q G<. \ _ . .. _,
LATITUDElLONGITUDE(OPTiONAl) - HORIZONTALUAIUM: SOURCE: UG?~(fype}:
( ##Q - ## - ##.##' or ##.###:I#1j U NAn 1927 U NAD 1983 U USGS Quad Map
Company NAIC Number
ZIP coqg
o 2lf77
U Other:.
SECTION B - FLOOD INSURANCE RATE MAP (ARllJIHFORMAnoN
81. NFl? COM~UNITY NAME & COMMUNITY NUM8ER ~L I..OUNTY NAM~ _ L ' 83. Sl'ATE ,0
~~~ od- Sfr"~e\4 ~4IS~1z.- , La",p LL>U~.T1 df'....
84. MAP AND PANEL- 85. SUFFIX 86. FIRM INDEX. 97. FIRM PANEL tio. i=i..ucib 89. BASE FlOOD ELEVATlON(S)
NUM8ER . DATE ,crr=CTIVE1REV1sEDDATE Z~~(S} (ZoneAOyYSe depth offlooding)
L\ IO::iq c.. \ It.ote. F h JlIML'Z"q'tf,:r~ .h1'f~L ^ !l10R- -J-w 7-~ X
810. Indicate the source of the Base Flood Bevation (BEE) data or base flood depth entered in 89. .
U FIS Profile ~IRM '.U Community Detennined , U Otl1er(Desaibe):
811. Indicate the elevation datum used for the 8FE in 89: Q{NGVD 1929 U NAVD 1~ U Other (Describe):
812. Is the building located in a Coasta.l8arrier Resources System (C8RS) area or OtheJWISe Protected Area (OPA)? U Yes ~o
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. 8uilding elevations are based on: UConstruction Drawings* Bwlding UnderConstruction* UFinished Construction
' "A new Elevation Certificate will be required when construction of the building is compies.
C2. Building Diagram Number 9? (Select the building diagram most similar to the building for which this certificate is being completed _ see
pages 6 and 7. If no diagram aCC1.Jrately represents the building, provide a sketch or photograph.)
C3. Elevations - Zones A 1-A30, AE, AH, A (with 8FE), VE. V1-V30, V (with BrE), AR, ARiA, AR/AE, ARiA 1-A30, ARiAH, AFiAO
Complete Items C3a-i below according to the building diagram specified in Item C2. Slate the datum used. If t'1e da~um is different fr:::m
the datum used for the 8FE in Section 8, convert the datum to that used fur the EFE. Show field measurements and datum conversion
'calcUlation. Use the space provided or the Comments area of Section 0 or Section G, as appropriate, to document the datum conversion.
Datum ..k\f,;,vOI ZOt Conversion/Comments ~ :(2. eVe'i5-e..-
Eieytion reference ;'ark used ~~ ~v~~ces the elevation reference mark uS~d a~pear on the FIRM? U Yes 1t::J-No:
ClY'a) Top of bottom floor (inducing basement or enClosure) 51 2.. ,!l. fl( ) ~ ;
a;tb ) Top of next higher floor -5 1.5 ...l ft.( J ~ / REGISTERED '\
o .9 80ttom of lowest horizontal structural member 01 zones cniy) A) ~. _ fl. ( ~ ~ PROFESSIONAL
rIa" 9) Attached garage (top of slab) 5 ILt ...!i fl. ( ) -g -g LAND SURVEYOR
!lYe) Low:s: elevation of machinery ancilor equipment c 5 _ ~. ; //. /) 1'-;-.".
./ servlcmg the building ~7 I .2 n.( ) E ~ J ff M {/r (o::J&::L.....
~ J} Lowest adjacent grade (LAG) Z::;, ~ .' z... fl.( ) ~ ~ I OREGON
rif g) Highest adjacent orade (HAG)Z;:; J L} .1- ft. ( .) ~ . B JULY 20, 1993
~ . - . .. , . /' ~ '" I REX A 8t: I L
!::! ?) No. or permanent openings (flood vents) within 1 ft. aoove aOJacent grace ~ /" = \... #2AOi'./
ftYi) Total area of alJ permanent openings (flood vents) in C3h ~ IJCJ'2. sq. Ul.. (~..) --..67/.7. Iz.- 6' 10 3
SECTION D .. SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect autt-.crized by law to certify elevation information.
I certify that the information in Sections A, B, and C on this certificate represents my best eiiorts to interpret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 1 a U. S. Code, Section 1001.
CERTIFIER'S NAM~ I\.r;) -L LlCE.1o.fSE NUMBEr< P c
K"" e'>C /-; ~ r?r'...A2- _ .."'..... ..__ L: / '2ton ( c7
TITLE s. U. y-~. e1' -L\.;; ~ q; ~ "'-V COM>AN r -'i3,.. UlA41 EJ"..; I " ~ ;;''--''''"5 -.Kcc.
ADDRESS 3 \ (J .. ~ ff~ <S.~ ~r - , ~J.TY_ S p-r YV\J h' e l,:;e~~~~ 1Z ZIP CODE q 74-7 I '
SIGNATURE /7. /J., L7 .-/-- ~c /78 Zt:;o/7 Il::.Le:PHONE;-_ ) / 3
//~ fJ/ ~~ . )(AY\ e...~ I v {?'-II _ 7'i-&-{)C?J 7
FCl'vlA Form 81-31, AUG 99 SEE REVERSE SIDE FOR CmmNUATION Ri=PI "'rc~ ^' Inn...., "'"" ,.... r-,,",,~.~......
IMPORTANT: In these spaces, copy the ~ Jsponding information from Section A. ,
BUILDINGtTREET ADDRESS.' ~c!uding Apt.. Unit. Suite. and/or Bldg. No.) OR P.O. ROUTE AND SOX NO.
t '3 C; {J(? vO\.~ (~U\1';:::>
CITf ',- - - - 0 - ,- - STATE Z!P CODE
~ or,"y"\c,-h'GlJ {)j2..., CJ"71f7r
" ",,-' .
I For Insurance Company Use:
Polic,! Number
C.::mpany NAIC Numcer
SECTION D _ SURVEYOR. ENGINEE.~, OR ARCHITECT CERTlFlCATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official. (2) insurance agent/company, and (3) building owner.
I COM~!=-NTS C ~ " ,h',." \/ 1 , \....., I. l I -'
'* (' ',+'1 Ch r -, P' ,..... '7-~."-':M.{ T:1 '" "oJ,., ~ V <L- "'" '" j '" 0.\:) e ""\ "''''1'-<4 V <C ~ NL+ ,,^ -\'1,\<2-
~ h" eo d7 C L< ,b '" + -\'\..z "\'\ ( (/ 9"'K t <>,.- (u ...1" ,<:of LL""h r,T +~ <; {1.... tLt '<J e d Co (11 "V o.f .
CL7t'~ cw...d, -nf1_(lYS~6V\ \.-.avv",,~ a", e.lcl/a..t~o'" C!:A~ 512..6\ C,\~\L,{ OA.RIN\. /),V\.Jt:<dJ'v<1=c..(
<to e,(~iftLn~ t=; '9. \ \ DtoVDI2~ VJ/L'S. u<;e) u<:;' k Q,"su-s cl elevAhOVl~ ~levecl1.,
U 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 E3. If the Bevation Certiiic3te is intended for use as supporting
information for a LOMA or LOMR-F Section C must be campJeted. .
E 1. Building Diagram Number ' (Select the building Ol3gram most similar to the building fer which this certificate is bei'ng completed -
see pages 6 and 7. If no diagram accUrately represents the building, provide a sketch or pl~~...ph.)
E2. The top of the bottom floor Qncl':lding basement or enclosure) of the building is I I ~ ft.(m) I I lin.(cm) U above or n U below
(check one) the highest adjaCent grade.
E3. For Zone AO only: If no flood depth number is available, is the top of the ~.k.... floor elevated in a......... Janca with the community's
floodclain management ordinance? I,' I Yes U ,No LI Unknown-. The local official must certify this i.f..........t:on in Section G.
: ' SECTION F _ PROP.eRTY OWNER (OR OWNER'S REPRESENTATIVE) CERTlACATlON
The property owner or owner's authorized representative who completes Sedions A, 8, and E for Zone A (without a FEMA-issued or
community-issued 8FE) or Zone AO must sign here,
PROPERTY OWNER'S OR OWNER'SAUTHORlZED REPRESarrATIVE"SNAM~
CITY
DATE
STATE
ZlP CODE
ADDRESS
SIGNATURE
TELEPHONE
COMMENTS
1-1 CheCK here if attachments
SECTlONG:COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or orciina~administer the cmnmurrity's f100dpiain management erdinance can compie!e
Sections A, 8, C (or E), and G of this Elevation Certificate. Complete the appiicable item(s) and sign below.
G1. U The information in Section C was taken from other doCtlmentation that has'been signed and embossed by a licensed surveycr,
engineer, or architect who is authorized by state or local law to certify elevation infcrmation. (Indicate the source and date of the
elevation data in the Cemments area below.)
G2. U A community official completed Section E fer a building Icc:ateri in Zone A (without a FaI.A,-issued or ccmmunit,!-issued EFE) or
Zone AO.
G3. U The following information (Items G4-G9) is provided fcr community ficcdeiain management purocses.
I G4. FE:RMIT NUMBER I Go. DAI ~ PERMIT ISSUED ! Go. UAI'E C~~Ti~iC;"Tc Of COMFLlANCEiCCCUFANCY
, I 1~~U=0
-.... .....-
G7. This permit has been issued fer: U New CcnstruC'jcn U substantiallm~rovemem
Ga. Elevation of as-built lowest floor (induding basement) of the building is:
G9. BFE or (in Zone AO) depth of flooding at the building site is:
LOCAL OFFICIAL'S NAME
. _ ft.(m) Datum:
. _ ft.(m) Datum:
TITLE
COMMUNITY NAME
SIGNATURE
TELEPHONE
DATE
COMMENTS
1-1 CheCK here if attachments
REPLACES ALL PREVIOUS EDITIONS