HomeMy WebLinkAboutFEMA Application 2002-1-23
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h:OERAL EMERGENCY MANAGEMENT A<:._.ICY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Important: Read the instructions on pages 1 -7.
SECTION A - PROPERTY OWNER INFORMATION
~'6 9'.\ "t-
O.M.B. No. 3067-0077
Expires July 31, 2002
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BUILDING OWNER'S NAME .
:-fl2.N \ "';) ~ ~ ~
BUILDING STREET ADDRESS (Including Apl, Unit, Suite, andlor Bldg. No.) OR P,O. ROUTE AND BOX NO.
b " .., ~ ~V\9-o N L. ~ e:
CITY STATE
'5PRIN"e=It\.O 012...
. PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number\.~al Description, etc.)
. \..0"'(' 101 l.JN\.. \.-l'\to.1tSl~ ~ '2".D&=- ,..o\:)rT\~~ .
BUILDING USE (e.g., Residential, Non-residential, Addition, Accessory, elc. Use Comments section if necessary.)
. R~SI(:)E"''TI~ ' . .
LATITUDElL,ONGITUDE (OPTIONAL) ,'X: HORIZONTAL DATUM: SOURCE: U GPS (Type):
( 'It#". ##'. ##.##" or ##.#####") L.:.J'NAD 1927 U NAD 1983 U USGS Quad Map
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ZIP CODE ..J
~-r {.1& '. , '
U Other:
SECTION B - FLOO.D INSURANCE RATE MAP (FIRM) INFORMATION
81. NFIP COMMUNITY NAME & COMMUNITY NUM8ER B2. COUNTY NAME 83. STATE
"S.PRIN.G;F'IC\..c 4-\~ 5"'1 'L ~E ()~ '
84, MAP AND PANEL 85. SUFFIXB6. FIRM INDEX 87, FIRM PANEL B8. H.6oD .1 89. f1A~E FLOOD ELEVATION(S)'
NUMBER _ DATE EFFECTIVE/REVISED DATE ZONE(S) . .' (Zone AO, use depth of flooding)
~\O~-=t C \\<..1 r ' J....ie: tJ \,..,..'\' JuNt, " \~" . Ae ' , c:5\C'7 " '.
B 1 O. Indicate the source of the Base Flooq Elevation (BFE) data or base flood depth entered in B9.
UFIS Profi'le 'U FIRM , . ~Community Determined U Other (Desqribe):
B11. Indicate the elevation datum used for the BFE in 89: ~GVD 1929 U NAVD 1988 U Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? U Yes ~No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C . 'Jilding elevations are based on: UConstruction Drawings* UBuilding Under Construction* UFinished Construction
* A new Elevatfon Certificate will be required when construction of the building is complete.
C2. Building Diagram Number..8.- (Select the building diagram most similar to the building for which t.his 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 BFE), VE, V1-V30, V (with BFE), A~, ARIA, ARlAE, ARlA1-A30,ARlAH, ARlAO
Complete Items C3a-i below according to the building diagram specified In 'Item C2. State the datum used. If the datum is different from .
the datum used for the BFE in Section B, convert the datum to that used for the BFE: Show fil;!ld'measurements and datum conversion
calculation. Use the space provided or the Comments area of Section D or SectionG, as appropriate, to document the datum conversion.
Datum'" Conversion/Comments . . .
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? U Y es ~ No
o a) Top of bottom floor. Oncluding basement or enclosure) -so \1 ',:,~ ft.(m) j
o b) Top of next higher floor . 'S\ + . ~ ft.(m) ~. ~
(3 0 ;:,,,;torT: :A 1~,I'eSII'..:..:"'~..l..1 ",l,~';l~;al.memoer (V zone", ojily) . _ ,1.~m) ~ ~
o d) AttaChed garage (top of slab) '::> 11- '. ..::L.ft.(m) ~ ~
o e) Lowest elevation of machinerY and/or equipment ~ ~
servicing the building No If'\.. _ ft:(m) ~ ~
o 1) Lowest adjacent grade (LAG) ~ I 't . ..::L. ft.(m) :E j
".q GI CI)
Og) Highest adjacent grade (HAG) S l ~ . ~ ft.(m) ~
o h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade 9 ~
o i) Total area of all permanent openings (flood vents) inC3h ~O \ \ sq. in. (sq. em)
REGISTERED' ~
. PROFESSIONAL
~ LANq .~~J~~" ;
~L....~ '
,\J" OREGON"
FEB. 19, 1999
, JAMES W. COLTON
" . ~5.B756 #
IMPORTANT: In these spaces, copy the cor, onding info~ation from Section A.
BUILDING STREET ADDRESS (Including Apt.. Unit, Suite, and/or Bldg. No.) O~ P.O. Ruu'rf ANU ~O^ NC.
b~",," ~N I...~~E. _ _____.
CITY a..... r'\ STATE LI.... CUUI:
~,N~\ ,............... at-:- . 4141g
For Insuran~..~,?~pany~s.~:.; _"~~~~
POlicY-Nuintier '. ,- ,'.' . -, 1.""
;"j . : -,-,,,
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COmpany NArc -ti'E!i:"" ---.. ,.",
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SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUEQ)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenVcompany, and (3) building owner.
COMMENTS
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1-' Check here if attachments
SECTION E. - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and ZONE A (WITHOUT BFE)
=or Zone ~O and Zone A (without BFE), complete Items E1 through E3. If the Elevation Cerlificate is intended for l.'se as supporting
1formation lor a LOMA or LOMR-F, Section C must be completed. " .
:1. Building'Diagram Number " (Seled the building diagram most similar to the building for which this certifiCate is being complete.d _
see pages 6 and 7.. If no diagram accurately represents the building, prov.j~e a sketch orphotograph~) . ' . ;.", . .
:2. The top of the bottom floor Oncll:lding bas~ment or enclosure) of.the building is ,., ~ ~;(m)' I 'in.(an) U above or U below
, (check one) the_ hig~est adjacent grade. .;. _ .
:3. For Zone AO only: If no flood depth number is available, is the top of the bottom floot erev~ted in accordance with the communitY's '
floodplain management ordinance? I_I Yes :U No I_I Unknown. The local official must certify this information in Section G.
. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE)CERTIFIGATION
rhe property owner or owner's authorized representative who completes Sections A. B. and E for Zone A (without a FEMA-issue'd or
:ommunity-issued BFE) or Zone AO must sign here. . .,
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~ROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
\DDRESS
;IGNATURE
CITY
DATE
STATE
ZIP CODE
TELEPHONE
;OMMENTS
'-....:.1 Check here if attachments
SECTION G -COMMUNITY INFORMATION (OPTIONAL)
Ie local official who.is authorized by law or ordinance to administer the community's floodplain management ordinance caracomplete
!ctions A.'B; C (or E). and G of this. Elevation Certificate. Complete the applicable item(s) and sign below. , "
i: U The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor.
engineer,.or archited who is authorized by state or local law to certify elevation information. (Indicate the source and date of the
elevation data in the Comments area below.) .
:. U A community pfficial completed Section E for a building located in Zone A (without a FEMA'-issued or community-issued BFE) or
Zone AO~
. U The foii6wing information (Items G4-G9) is provided for Community floodplain management purposes. '
4. PERMIT NUMBERG5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
, ISSUED .
. This permit has been issued for. U New Construdion U Substantial Improvement -
. Elevation of as-built lowest floor Onduding basement) of the building is:
. 'BFE or On Zone AO) depth of flooding at the bLiilding site is:
)CAL OFFICIAL'S NAME
. _ item) Datum:
. _ item) Datum:
TITLE
)MMUNITY NAME
GNA TURE
TELEPHONE
DATE
)MMENTS
I ~A ~t'lrm A1.':ti AII~ 00
, Check here if attachments .