HomeMy WebLinkAboutFEMA Application 2002-1-22
. .
Pt....,c:RAL EMERGENCY MANAGEMENT A(ji!f'~;;~Y
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
O.M.B. No. 3067-0077
Expire~.. ~uly 31, fOP?
" . important: Read the instructions on pages 1 - 7.
SECTION A - PROPERTY OWNER INFORMATION
~~~jtl).~i~i[~I~!l1p!Q~~~i~t~~f::?;~~~'
~. ',' "~~~dJi1;~~~i~~
,,:~~~..'::::t:~~rT~
ZIP Co.DE ~ - -
4i 4-1ca.
- buiLDING o.WNER'S NAME .
e~~c:E: ,\t-l\e<:H~"" c~~,~t'l\ \4t)""'E~ , " __'
BUILDING STREET ADDRESS (Including Apt, Unit, Suite, and/or Bldg. No.) o.R P.O. KUlITE AND Bo.X NO..
(0 1 ~"Z.. I\~o.~ \...A"-\ c "
CITY STATE
S.~N c::\ f\-&..o ~(2...
'PRo.PERTY DESCRIPTION (Lot and Block Numbers, Tax l.&rce' Number, Legal Description, etc.)
, ~"'t' \0'2.. l.Cv\ ~M~N~ 2' AOO IT'It.~
, BUILDING USE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use Comments section if necessary.)
~ES~I~
LATITUDE/Lo.NGITUDE (o.PTlo.NAL) 'HORIZo.NTAL DATUM: So.URC,E: U GPS (Type):
( t#f - ##' - ##.##' or ##.#####") ~NAD 1927 U NAO 1983 U USGS Quad Map
U Other: '
SECTlo.N 8 - FLo.o.D INSURANCE RATE MAP (FIRM) INFORMATlo.N
B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER I B2. CO~N2:N'E.NAME ' ~i ~IAI~,,'),
SrillNG.~a.o 4\~S~'t- ~ '--J_
, 84. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL 88. fL00iJ
NUMBER DATE EFFECTNElREVISED DATE Zo.NE(S)
.6,. \ () ~ 9 c:. , \.CD'1 F .J.,..e 2., \~'9"'1 .J.J\4C '2..1 \ .Yl ,Ac.
B10.lndicate the source of the Base Flood, Elevation (BFE) data or base flood depth entered in B9.
, U FrS Profile U FIRM , ' ~ Community Detennined ,U Other (Describe):
B11. Indicate the elevation datum used for the BFE in 89: ~NGVD~929 U NAVD 1988 U Other (Describe):
812. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise P~otected Area (OPA)?
Designation Date:
~9. 8AS~Fi..06DELEVATION(S)'
(Zone Ao., use depth of flooding)
'S\\. 5, '
U Yes-K...I No
/
,c
SECTlo.N C - BUILDING ELEVATION INFORMATlo.N (SURVEY REQUIRED)
Jilding elevations are based on:, UConstruction Drawings. UBuilding Under Construction. ~inished Construction
* A new Elevation Certificate will be required when construction of the building is complete. , '
C2. Building Diagram Number -1L- (Select the building diagram most similar to the building forwhich 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 BFE), VE, V1-V30, V (with BFE), AR, ARiA, ARiAE, ARiA1-A30, ARiAH, ARiAO
Complete Items C3a-i below according to the building diagram specified in item C2. State the datum us~d. If the datum is different from
the datum used for the BFE in Section B, convert the datum tQ that used for the BFE. Show fi~ld' 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 eievation reference mark used appear on the FIRM? U Yes ~o'
o a) Top of bottom floor. (induding basement or enclosure) os. '1. .; "Z. ft.(m) 0;
..
o b) Top of next higher floor ~ \ c::. . ~ ft.(m) ~ · REGISTERED
o .:.) r3H...... ..I.1"'".....l J.",,-:z.~f't.al stF".:I~....,.....,:".... (t' L\JII\:::" ullin . ~ ft.(m) ~ ~ PROFESSIONAL
o d) Attached garage (top of slab) ~ \4- ....L ft.(m) ~ ~ ' LAND SUR~..QR
o e) Lowest elevation of machinery and/or equipment ~ ~ \... ~ .'
servicing the building NoI t\ . _ ft:(m) ~ ~ ~ . l... - '
o 1) Lowest adjacent grade (LAG) ~,~ . ~ ft.(m) ~]. 0 OREGON
CD V)
o g) Highest adjacent grade (HAG) 5' ~ . ~ ft.(m) ~ FEB. 19, 1999
o h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade \ +, ~' JAMES W. COLTON
o i) Total area of all pennanent openings (flood vents) inC3h \~e sq. in. (sq. em) '\ #58756
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION &f\U:~ \'2./~ lo~
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, a, and C on this certificate represents my best efforts to interpret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U. S. Code, Section 1001.
c~ -....IFIER.S NAME,. 1 /' LICENSE NUMBER ~ 5 ""\c:,
...JAM.~~ v-.. ,-ClI..\OI"o ~, L~. ... ~ I.J 'c:lo
TIIL.e _ <. r=::v L Co.MPANY.NAME
~:> ~up.."C,,4 n~- N~:' -~~~e>>~o't':'l-
ADDRESS ""'2. 7:s -S CITY ,.. ~ ~e: STATE ZIP CODE
p.o. ~" _ OJ", 0"'" 4'14-e.t.
SIGNATU~, ~ '- _ ~ DATE \ I t.1-/o "- TELEPHONE 54-I. ~ 4- 4,... \ 8 "S 1-
'"
,
_~.... r-__':",~.. AIIr'lt"\t'II
C"r-r- nr-, ,r-n",e: CIne: eno f"n"'TI"" 11ITIf"'l"1
Ql:OI U'l:C:: flll OQI=\Ilnll~ I=nITlnN~ '
IMPORTANT: In these spaces, copy the co. ,on ding information from Section A.
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROU"f~ ANU i:i0;( i~u.
61~1.. "~N,' l..~E-
.' ..::~~~1~;~;;r~,~~p:nt\JS&:,
'. .-:.i7::f:::'i" .:
:ii,t~\',.Ja.!;~_~:!!:.;,:;;' ",,"
:,..~
. .......
. ,..~'~
CITY
'Sp~,N~ na.?
STATE
CQ.. .
<=t~ ~~~E l;~B[~j~~~~~[~:,;,,"O, '.'.
.,~ _. ''''';,'. ~
::"':1:::,,':
o"o,SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUEQ)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenVcb'mpany, and (3) building o......ner.
COMMENTS
( ..
I I Check here if attachments
SECTION E, - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and ZONE A (WITHOUT BFE)
=or Zone 1;0 and Zone A (without BFE), complete Items E1 through E3. If the Elevation Cettificate is intended for use as supporting
nfonnation for a LOMA or LOMR-F, Section C must be completed. .
: 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. Ifno diagram accurately represents the building, provide a sketch or photograph'~) i ' .'" ".:
~. The top of the bottom floor (incl<<:Jding basement, or enClosure) of the building is 'I lft.(m).' I ,!in.(ern) U above or U below
(check one) the highest ~djaCent grad~.' ,0 , " ,
:3. For Zone AO only: If no flood depth number is available, is the;top of the bottom floor elevatedi., 'accordance with the commui'iifys '
floodplain managementordinance?I_1 Yes' LJNo I_I Unknown. The local official must certify this information in Section G.
. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFlqATION
The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A (without a FEMA-issiJe'd or
:cimmunity~issued BFE) or Zone AO must sign here. '
:lROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
~DDRESS
CITY
STATE
ZIP CODE
)IGNATURE
DATE
TELEPHONE :
:;OMMENTS
I_I Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPT,ONAL)
Ie local official who,js authorized by law or ordinance to administer the community's floodplain management ordinance can complete
:dions A,B, C' (or E), and G of this Elevation Certificate. C.omplete the applicable item(s) and sign below.
I. U The information in Section C' was taken from other dociJment?tion that has been signed and embossed by a licensed surveyor,
' engineer, or architect who is.a~thorized by stat~ or local law:to certify elevatiQn information.. (Indicate the source and date of the
elevation data in the COlT1ments area below.) '.
~. U A coi'nmunityofficial completed Section E for a ~uilding IQ~t,ed in Zone A (without a FEMA-issued or community-issued BFE) or
,Zone AO.
:. U The following information (Items G4-G9) is provided for c;ommunity floodplain management purposes. ,
4. PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATe CERTIFICATE OF COMPLIANCE/OCCUPANCY
ISSUED '
. This permit has been issued for: W New Construction U Substantial Improvement
. Elevation of.as-built lowest floor (including basement) of the building is: ';"
.BFE or (in Zone AO) depth of flooding at the building site is:
)CAL OFFICIAL'S NAME TiTlE
. _ ft.(m) Datum:
. _ ft.(m) Datum:
)MMUNITY NAME
GNATURE
)MMENTS
TELEPHONE
DATE
_1-:1 Check,here if attachments
4A ~"rm $l1-~1 dllr. co