HomeMy WebLinkAboutFDP201800020 Affidavit 2018-10-18DEPARTMENT OF HOMELAND SECURITY
LEVATIONION-FEDERAL ELEVATION FORM
MANAGEMENT AGENCY Expires February 28,2014
Public reporting burden for this data collection is estimated to average 1.25 hours per response. The burden estimate includes the time for reviewing instructions,
earth Ing existing data sources, gathering and mai me ining the needed data, and com plating and su bm itting the form. Th is collection is required to obtain or retain
benefits. you are not required to respond to this collection of information unless a valid 0Me control number is displayed on this form. Send comments regarding the
accuracy ofthe burden estimate and anysuggestions for reducing this bumen to: InformationCol lectionsManagements Department ofHomeland 5e��itcompleted
,F deral
Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0015). NOTE: Do not send m lsted
form to this address.
This form must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS-FEMA National
Flood Insurance Program (NFIP) Elevation Certificate may be submitted In lieu of this form for single structure requests.
For requests to remove structure on natural grade OR on engineered fill from the Special Fload Hazard Area (SFHA), submit the lowest adjacent grade (the lowest
ground touching the structure), induding an attached deck or garage. For requests to remove an entire parcel of land from the SFHA, provide the lowest lot elevation;
r, if the request involves an area described by metes and bounds, provide the lowest elevation within the metes and bounds description. All measurements are to be
rounded to nearest tenth of a foot. In order to process your request, all information on this form must be completed in its errttrety. Incomplete submiubrts will
result in processing delays.
1. NFIP Community Number: S/a706 Property Name or Address: ,S ST/'Lfi d- /-�S 6�
2. Are the elevations listed below based on ®existing or ❑proposed conditions? (Check one)
3. For [he existing or proposed structures listed below, what are the types of construction? (check all that apply)
❑ crawl space ® slab on grade ❑ basement/enclosure ❑ other (explain)
4. Has DHS- FEMA identified this area as subject to land subsidence or uplift? (see instructions) ❑ Yes ®No
If yes, what is the date of the current re -leveling? / (month/year)
S. What is the elevation datum? ❑NGVD 29 ®NAND 88 ❑Other (explain)
If any of the elevations listed below were computed using a datum different than the datum used for the effective Flood Insurance Rate Map
(FIRM) (e.g., NGVD 29 or NAVD 88). what was the conversion factor?
Local Elevation +/- ft. = FIRM Datum
6. Please provide the Latitude and Longitude of the most upstream edge of the structure (in decimal degrees to the nearest fifth decimal place):
Indicate Datum: ❑ WGS84 ® NAD83 ❑ NAD27 Lat. 3g .Cx2%v9r Long. 7$ .3o ryo"
Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degrees to the nearest fifth decimal place):
Indicate Datum: ❑ WGS84 ❑ NAD83 ❑ NAD27 Lat. Long.
Lowest
Address Lot Number Smock Lowest Lot Adjacent Rase Flood gFE Source
Number Elevation* Grade To Elevation
$1A7/o,✓ 6oMlZ
This certifcation is to be signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation
information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable
ICertifiers Name: SL.x/% 2 % LUNS I License No.: o3S79/ I Expiration Date: 0/ _20 I
Company Name:
Email:
Telephone No.:
Date:
"For requests involving a portion of property, include the lowest ground elevation within
the metes and bounds description.
Please note: If the Lowesi Adjacent Grade to Structure is the only elevation provided, a determination
will be issued for the structure only.
Lic. No. 035791
Seal (optional)
DNS -FEMA Form 088A-26A, FEB 11 Elevation Form MT-1 Fotm 2 Page 1 of 2