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Home My WebLink AboutFEMA Application 2002-1-22 . . t _..IERAL EMERGENCY MANAGEMENT AL ,CY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION . culLDING OWNER'S ':![\ME '-" 'e'P- ~ I....,".~ . . '~f2\3<'c. \f'J \c.'-""' r- \ <::'..1 ~ \ CloN\ H.O..."C BUILDING STREET ADDRESS (Including Apt, Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. '=>fc.9 \ J'v...t;l..r:::.\oJ ~t4C: CITY STATE ~N.aAaO C~ . PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) , \..e:.T 4b \..CJI ~D4~a' 'Z.~ AcO t"iL ~ BUILDING USE ~.9:, Residenti~ Non-residential, Addition, Accessory, etc. Use Comments section if necessary;) R'i:"':;)It:)~ \l~ ITUDElLONGITUDE (OPTIONAL) .IV: HORIZONTAL DATUM: SOURCE: U GPS (Type): I iF#". ##' - ##.##' or ##.#####") 0 NAD 1927 U NAD 1983 U USGS Quad Map O.M.B. No. 3067-0077 Expi:.e~July 31,2002 SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION ~li~EiJilapfi!i~i~~~~~.~~i~~s;~~~;~'J ZIP CODE ,141~ ., ,;::,-;-=-~;~~~~ U Other: B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER B2. COUNTY NAME ~P-.i~Me..c A, IS '5" Z. lA~€. 64. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL 88. FLUUU NUMBER DATE EFFECTNElREVISEDDATE ZONE(S) 4-\O~~ C \\b1 r ~"le 2, \~..,' ,.Ju~e ~ \", AE B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. U FIS Profile U,FIRM I.CI.Community Determined U Other (Describe): B11. Indicate the elevation datum used for the BFE in 89: ~NGVD 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)? Designation Date: SECTION C. BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Jilding efevati,ons are based on: UConstruction Drawings" UBuilding Under Construction" ~inished Construction A new Elevatlon 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 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 A 1-A30, AE. AH, A (with BFE), VE. V1-V30, V (with BFE), AR, ARIA, ARlAE, ARIA 1-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 field' measurements and datum conversion calculation. . Use the space provided or the Comments area of Section D or Section G, 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 Yes ~ No o a) Top of bottom floor. (including basement or enclosure) ~ ,7.. : ~ ft.(m) ~ o b) Top of next higher floor ~\ OS . -L ft.(m) ~ ' G I.;} O~llUlll uf luwes{ nonzoniai siruciurai memoer (V zOnes only) . _ ft.(m) * {l o d) Attached garage (top of slab) ~ \ ~ . .:L ft.(m) ~ ~ o e) Lowest elevation of machinery and/or equipment W .. / ~.~ servicing the building NolA. . _ ft.(m) ~ c;; o 1) Lowest adjacent grade (LAG) ~ I ~ . to ft.(m) ~ ~ b ~lI) o g) Highest adjacent grade (HAG) S \ ~ . _ ft.(m) ~ o h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade \ ~ ~ o i) Total area of all permanent openings (flood vents) inC3h \ ~b ~ sq. in. (sq. em) c : 83. ~-{j(i~ I CK. . 89. BA~8 FLOOD ELEVATION(S)' I (Zone AO, use depth of flooding) sn.'L ' UYes ~NO \' . REGISTERED PROFESSIONAL ~ND SUR~ ~ \...- U OREGON FEB. 19. 1999 JAMES W. COLTON , #58756 , SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION E.x.n~ \"1_/31/ D~ This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation infonnation. I certify that the information in Sections A, B. and C on this certificate represents my best efforts to interpret the data available. I understand that any false statement maybe puniShable by fine or imprisonment under 18 U.S. Code, Section 10.0.1. C""~TIFIER'S NAME LICENSE NUMBER ~~€~ W Co~ul'\ O~. \""";), .. "S'B"1~fo TI,,-e COMPANY NAME _ \...AND ~v\2-\J€1d- f'b~ -l'4.'C:':l'5 -rA.~:'o€NOelL ADDRESS?.o. ~c>>< '2.1..1~'S CITY e~G€,NE ST~l. Z'Pcf~~'t.. SIGNATURE :Cr:: L.. Cf2- DATE I 1/ TELEPHONE .14S" . \ 7....,o"t.. ~ ,~4-4-. Ul '- I=r=MA I=nrm R1-. I /r, QQ c:,::,:: 0,::\1'::0';:':: C:ln,:: f::()0 ('()I\JTII\JIIATI()I\J oeol ^f"'ec ^ 1 1 n[")~' """ 1<"' ~I"\'TI^.'" IMPORTANT: In these spaces, copy the c~?~onding infonnation from Section A. "if BUILDING STREET ADDRESS (Including A~t.. Unit. Suite. and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. '-" \ I ""~ '-ol\"lC . ... Clli' STATE ZIP CUOI: Sfl?\~ccr\e-o ~. 4141~ ,F()r'lns~fanceC()mpany "Jse:. , "p~i;~;~.~in~~i ;,;J~~i!~,,,; "-'- ~~;Z~~~~~,~r " ' "'.:."J...'.. ] ", 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 , 1-' Check here if attachment SECTION E, - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and ZONE A (WITHOUT BFE) For Zone ~O and Zone A (without BFE), complete Items E1 through E3. 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 (Select the building diagram most similar to the building for which this certificate is being completed _ see pages 6 and 7. If. np diagram accurately represents the building, p~ovide a sketch or photograph.). ' '., , . E2. The top of the bottom floor (incll:'ding basement. or enclosure) of the building is " I ft.(m) , I "in.{an) U above or U below (check one) the highest adjaCent grad~.' . :3. For Zone AO only:, If no flood depth number is available, is.the top of the ,bottom f1oor.elevatediA accordance'with the community's floodplain management ordinance?'I_' Yes: L I No 'I I Unknown. The local official must certify this infor:mation in Section G. . SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE)CERTIFIGATION The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A (without a FEMA-issued or community-issued BFE) or Zone AO must sign here. ' . PROPERli' OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE TELEPHONE ZIP CODE SIGNATURE COMMENTS DATE I_I Check here if attachments SECTION G - COMMUNITY INFORMATION (OPT!ONAL) he local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can compl03te ections A, B, C (or E), and G of this Elevation Certificate. C.omplete the applicable item(s) and sign below. 1: U 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 by state or local law to certify elevation information. (Indicate the source and date of the elevation data in the CommentS area below.). " ' 2. U A community official completed Section E for a building lo~ted in Zone A (without a FEMA-issued or community-issued BFE) or Z~~. . 3. U T.he following i.nformation (Items' G4-G9) is provided for community floodplain management purposes. 34. PERMIT NUMBER ' G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED 7. This permit has been issued for:. '." U New Construction U Substantial Improvement 3. Elevation of as~built 10wesUloor.{including basement) of the bUilding is: l.BFE or (in Zone AO) depth of flooding at the building site is: OCAL OFFICIAL'S NAME . _ft.(m) Datum: . _ ft.(m) Datum: TITLE :OMMUN/li' NAME IGNATURE OMMENTS TELEPHONE DATE I_I Check here if attachments MA Form R 1.::\ 1 Al Ie:; ~~