HomeMy WebLinkAboutFDP201900012 Document 2019-11-08DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.6. 140.1660-WIS
PROPERTY INFORMATION FORM ExpiresFcbnmry28,2014
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1.63 hours per response. The burden estimate Includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. This collection Is required to obtain or retain
benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing this burden to: information Collections Management, Department of Homeland Security, Federal
Emergency Management Agency,1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0015), NOTE: Do not send your completed
form to this address.
This form may be completed by the property owner, property owner's agent, licensed land surveyor, or registered professional engineer to support a request for a
Letter of Map Amendment (LOMA), Conditional Letter of Map Amendment (CLOMA), Letter of Map Revision Based on fill (LOMR-F), or Conditional letter of Map
Revision Based on Fill (CLOMR-F) for existing or proposed, single or multiple lots/structures. In order to process your request, all information on this form must be
completed in its entirety, unless stated as optional. Incomplete submissions will result in processing delays. Please check the item below that describes your request:
Q LOMA A letter from DHS-FEMA stating that an existing structure or parcel of land that has not been elevated
by fill (natural grade) would not be inundated by the base flood.
❑ CLOMA A letter from DHS-FEMA stating that a proposed structure that is not to be elevated by fill (natural
grade) would not be inundated by the base flood if built as proposed.
❑ LOMR-F A letter from DHS-FEMA stating that an existing structure or parcel of land that has been elevated by
fill would not be inundated by the base flood.
A letter from DHS-FEMA stating that a parcel of )and or proposed structure that will be elevated by fill
❑ CLOMR-F would not be inundated by the base flood if fill is placed on the parcel as proposed or the structure is
built as proposed.
Fiff is defined as material from any source (including the subject property) placed that raises the ground to or above the Base Flood Elevation (BFE). The common
construction practice of removing unsuitable existing material (topsoil) and backfilling with select structural material Is not considered the placement of fill if the
practice does not alter the existing (natural grade) elevation, which is at or above the BFE. Fill that is placed before the date of the first National Flood insurance
Program (NFIP) map showing the area in a Special Flood Hatard Area (5FHA) is considered natural grade.
Has fill been placed on your property to raise
ground that was previously below the BFE? ❑ Yes Q No If yes, when was fill placed?
Will fill be placed on your property to raise mm/dd/yyyy
ground that is below the BFE? ❑ Yes" Q No If yes, when will fill be placed?
mm/dd/yyyy
if yes, Endangered Species Act (ESA) compliance must be documented to FEMA prior to issuance
of the CLOMR-F determination (please refer page 4 to the MT-1 instructions).
1. Street Address of the Property (if request is for multiple structures or units, please attach additional sheet referencing each address and enter
street names below):
5885 Jarmans Gap Rd
2. Legal description of Property (Lot, Block, Subdivision or abbreviated description from the Deed):
TM P 056A 1-01-00-046A0
3. Are you requesting that a flood zone determination be completed for (check one):
❑ Structures on the property? What are the dates of construction? (MM/YYYY)
Q A portion of land within the bounds of the property? (A certified metes and bounds description and map of the area to be
removed, certified by a licensed land surveyor or registered professional engineer, are required. For the preferred format of
metes and bounds descriptions, please refer to the MT-1 Form 1 Instructions.)
❑ The entire legally recorded property?
4. Is this request for a (check one):
❑ Single structure
0 Single lot
❑ Multiple structures (How many structures are involved in your request? List the number: )
❑ Multiple lots (How many lots are involved in your request? List the number:
DHS - FEMA Form 086.0.26, FEB 11 Property Information Form MT-1 Form 1 Pago 1 of 2
In addition to this form (MT-1 Form 1), please complete the checklist below. ALL requests must Include one copy of the following:
Q Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted (property inadvertently located in the NFIP
regulatory floadway will require Section B of MT-1 Form 31
Q Copy of the Subdivision Plat Map for the property (with recordation data and stamp of the Recorder's Office)
OR
Copy of the Property Deed (with recordation data and stamp of the Recorders Office), accompanied by a tax assessor's map or other certified map
showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street Intersection that is
shown on the FIRM panel.
® Form 2 — Elevation Form. If the request is to remove the structure, and an Elevation Certificate has already been completed for this property, It may be
submitted In lieu of form 2. if the request is to remove the entire legally recorded property, or a portion thereof, the lowest lot elevation must be
provided on Form 2.
[�] Please include a map scale and North arrow on all maps submitted.
For LOMR-Fs and CLOMR-Fs, the following must be submitted in addition to the items listed above:
❑ Form 3— Community Acknowledgment Form
For CLOMR-Fs, the following must be submitted in addition to the items listed above:
❑ Documented ESA compliance, which may include a copy of an incidental Take Permit, an Incidental Take Statement, a "not likely to adversely affect"
determination from the National Marine Fisheries Service (NMFS) or the U.S. Fish and Wildlife Service (USFWS), or an official letter from NMFS or USFWS
concurring that the project has "No Effect" on proposed or listed species or designated critical habitat. Please refer to the MT-1 instructions for additional
information.
Please do not submit original documents. Please retain a copy of all submitted documents for your records.
DHS-FEMA encourages the submission of all required data In a digital format (e.g. scanned documents and images on Compact Disc ICD)). Digital
submissions help to farther DHS-FEMA's Dlgltal Vision and also may facilitate the processing of your request.
incomplete submissions will result in processing delays. For additional Information regarding this form, including where to obtain the supporting
documents listed above, please refer to the MT-1 Form Instructions located at http://www.fema.gov/plan/prevent/fhm/dLmt-I.shtm.
Processing Fee (see Instructions for appropriate mailing address; or visit http-//www.fema.gov/fhm/frM_fees.shtm for the most current fee
schedule)
Revised fee schedules are published periodically, but no more than once annually, as noted in the Federal Register. Please note: single/multiple
lots)/structure(s) LOMAs are fee exempt. The current review and processing fees are listed below:
Check the fee that applies to your request:
❑ $325 (single lot/structure LOMR-F following a CLOMR-F)
❑ $425 (single lot/structure LOMR-F)
❑ $500 (single lot/structure CLOMA or CLOMR-F)
❑ $700 (multiple lot/structure LOMR-F following a CLOMR-F, or multiple lot/structure CLOMA)
❑ $800 (multiple lot/structure LOMR-F or CLOMR-F)
Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to:
National Flood insurance Program.
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 by fine
or imprisonment under Title 13 of the united States Code, Section 1001.
Appllcanfs Name (required): ,Justin Shimp Company (if applicable): Shimp Engineering, PC
Mailing Address (required): 912 East High St Daytime Telephone No. (required): (434) 299-9843
E-Mail Address (optional): ❑ ay checking here you may receive Fax No. (optional):
correspondence electronically at the email address provided):
Date (required) 1 1 /08/20'19
Signature of Applicant equlred)
DHS - FEMA Form 086.0-26, FEB 11 Property Information Form MT-1 Form 1 Page 2 of 2
DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY
ELEVATION FORM
PAPERWORK BURDEN DISCLOSURE NOTICE
O.M.S. NO.1650-0015
Fxplres February 28, "14
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,
searching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. This collection is required to obtain or retain
benefits. You are not required to respond to this collection of Information unless a valid OMB control number is displayed on this Form. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal
Emergency Management Agency, 1800South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0015). NOTE: Do not send your completed
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 Neu of this form for single structure requests.
For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area (SFHA), submit the lowest adjacent grade (the lowest
ground touching the structure), Inducting an attached deck orgaroge. For requests to remove an entlre parcel of land from the SFHA, provide the lowest lot elevation;
or, if the request involves an area described by metes and bounds, provide the lowest elevation within the metes and bounds description. AN 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 entirely. Incomplete submissions will
result in processing delays.
1. NFIPCommunity Number: 51003 Property Name or Address:5885 Jarmans Gap Rd
2. Are the elevations listed below based on ■❑ existing or ❑ proposed conditions? (Check one)
3. For the existing or proposed structures listed below, what are the types of construction? (check all that apply)
❑ crawl space ❑ stab 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 X NAVD 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: ❑ WG584 ❑ NAD83 ❑ NAD27 Lat, Long.
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: ❑ WG584 ® NAD83 ❑ NAD27 Let. Ar .00YQ Long. — j,P 7 06OL
Lowest
Address
Lot Number
Block
Lowest Lot
Adjacent
Base Flood
Number
Elevation'
Grade To
Elevation
BFE Source
Structure
5875 Jarmans Gap Rd
46A
633.5
633.5
Powells Creek
This certification 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
by fine or imprisonment under Title 18 of the United States Code, Section 1001.
ier's Name:
License No.:
4s193
Expiration Date:
06/01/2020
any Name:
rSignature:
Telephone No.Engineering 434-227.514D
:
Fax No.
Date:
1IMSM19
` For requests Involving a portion of property, include the lowest ground elevation within
the metes and bounds description. Seal (optional)
Please note: If the Lowest Adjacent Grade to Structure is the only elevation provided, a determination
will be Issued for the structure only.
DHS - FEMA Form 086-0-26A, FE13 11 Elevation Form MT-1 Form 2 Page 1 of 2
DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY D.M.H. NO.1660-DOTS
COMMUNITY ACKNOWLEDGMENT FORM Expires February 28, 2014
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1.38 hours per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. This collection is required to obtain or retain
benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding
the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security,
Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0015). NOTE: Do not send your
completed form to this address.
This form must be completed for requests Involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of this request to
remove a property from the SFHA which was previously located within the regulatory floodway (complete Section B).
This form must be completed and signed by the official responsible for floodplain management in the community. The six dlglt NFIP community number and the
subject property address must appear in the spaces provided below. Incomplete submissions will result in processing delays. Please refer to the MT-1 Instructions
for additional Information about this form.
Property Name or Address: 5885 Jarmans Gap Rd
Community Number. 51003
A. REQUESTS INVOLVING THE PLACEMENT OF FILL
As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter of Map
Revision Based on Fill (LOMR-F) or Conditional LOMR-F request. Based upon the community's review, we find the completed or proposed project
meets or is designed to meet all of the community floodplain management requirements, including the requirement that no fill be placed in the
regulatory floodway, and that all necessary Federal, State, and local permits have been, or in the case of a Conditional LOMR-F, will be obtained.
For Conditional LOMR-F requests, the applicant has or will document Endangered Species Act (ESA) compliance to FEMA prior to issuance of the
Conditional LOMR-F determination. For LOMR-F requests, I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved
Independently of FEMA's process. Section 9 of the ESA prohibits anyone from "taking' or harming an endangered species. If an action might harm
an endangered species, a permit is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA.
For actions authorized, funded, or being carried out by Federal or State agencies, documentation from the agency showing its compliance with
Section 7(a)(2) of the ESA will be submitted. In addition, we have determined that the land and any existing or proposed structures to be removed
from the SFHA are or will be reasonably safe from flooding as defined In 44CFR 65.2(c), and that we have available upon request by OHS-FEMA, all
analyses and documentation used to make this determination. For LOMR-F requests, we understand that this request is being forwarded to DHS-
FEMA for a possible map revision.
Community Comments:
Community Official's Name and Title: (Please Print or Type) Telephone No.:
Community Name: Community Official's Signature: {required) Date:
B. PROPERTY LOCATED WITHIN THE REGULATORY FLOODWAY
As the community official responsible far floodplain management, I hereby acknowledge that we have received and reviewed this request for a
LOMA, We understand that this request is being forwarded to DHS-FEMA to determine if this property has been inadvertently included in the
regulatory floodway, We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway. We find
that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements.
Community Comments:
Community Official's Name and Title: (Please Print or Type) Telephone No.:
i�/�Nl� aV ,�s�L Abu.✓ .n�ce� 3 796
Community Name: Ll Commu lty Official's Signature (required}; Date:
DHS - FEMA Forth 066-0.26113, FES 11 Community Acknowledgment Form MT-1 Form 3 Page 1 of 1