The URL can be used to link to this page

Home My WebLink AboutE-ELEVATION CERTIFICATE - 1941 WALLENBERG DRIVE - SPRING CREEK (3)L S: DEPAMIINENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008 Federal Emergency Management Agency I Exoires February 28. 2009 National Flood Insurance Program Important: Read the instructions on pages 1-8. SECTION A - PROPERTY INFORMATION For Insurance Company Use: Al. Building Owner's Name Policy Number A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Company NAIC Number 1941 Wallenberg Drive City, Fort Collins State CO ZIP Code 80526 A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) Lot 18, Block 2, Hillpond On Spring Creek 2m P.U.D. A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.) Residential As. Latitude/Longitude: Lat. 40A33'48"N Long. 105A05115' Horizontal Datum: ❑ NAD 1927 ❑ NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. AT Building Diagram Number 1 A8. For a building with a crawl space or enclosure(s), provide A9. For a building with an attached garage, provide: a) Square footage of crawl space or enclosure(s) 0 sq ft a) Square footage of attached garage 633 sq ft b) No. of permanent flood openings in the crawl space or b) No. of permanent flood openings in the attached garage enclosure(s) walls within 1.0 foot above adjacent grade 0 walls within 1.0 foot above adjacent grade $ c) Total net area of flood openings in A8.b 0 sq in c) Total net area of flood openings in A9.b 702 sq in SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION cil NF1P Community Name & Community Number B2. County Name B3. State J City of Fort Collins 080102 Latimer CO B4. Map/Panel Number B5. Suffix B6. FIRM Index B7. FIRM Panel 88. Flood B9. Base Flood Elevation(s) (Zone Date Effective/Revised Date Zone(s) AO, use base flood depth) 080102C0979f F Dec. 19, 2006 October 20, 1998 AE 5002.0 B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9. ❑ FIS Profile E FIRM ❑ Community Determined ❑ Other (Describe) _ Bl 1. Indicate elevation datum used for BFE in Item 139: ❑ NGVD 1929 E NAVD 1988 ❑ Other (Describe) _ B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑Yes ENo Designation Date _ ❑ CBRS ❑ OPA SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: ❑ Construction Drawings' ❑ Building Under Construction' E Finished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations -Zones Al-A30, AE, AH, A (with BFE), VE, V1430, V (with BFE), AR, ARIA, AR/AE, AR/A1-A30, ARIAH, ARIAO. Complete Items C2.a-g below according to the building diagram specified in Item A7. Benchmark Utilized RM1 EL=5200.E Vertical Datum NGVD1929 Conversion/Comments _ a) Top of bottom floor (including basement, crawl space, or enclosure floor)- b) Top of the next higher floor c) Bottom of the lowest horizontal structural member (V Zones only) d) Attached garage (top of slab) e) Lowest elevation of machinery or equipment servicing the building (Describe type of equipment in Comments) f) Lowest adjacent (finished) grade (LAG) g) Highest adjacent (finished) grade (HAG) Check the measurement used. 5003.6 E feet ❑ meters (Puerto Rico only) 5013.6 E feet ❑ meters (Puerto Rico only) NIA ._ ❑ feet ❑ meters (Puerto Rico only) 5002.6 E feet ❑ meters (Puerto Rico only) 5006.0 E feet ❑ meters (Puerto Rico only) 5002.0 E feet ❑ meters (Puerto Rico only) 5003.2 E feet ❑ meters (Puerto Rico only) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certiry elevation information. I certify that the information 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 1001. E Check here if comments are provided on back of forth. ®� 1MP6RTA1IT: In these spaces, copy the corresponding information from Section A. I For Insurance Company Use: J ♦ Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. I Policy Number 1941 Wallenberg St City Fort Collins State. CO ZIP Code 80526 1 Company NAIC Number SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent1company, and (3) building owner. Comments 'Benchmark used was City of Ft. Colins ACBNW28-92 Elevation = 5007.48. 3 feet was added to our field shots to convert from 1929 Datum to 1988 Datum. The mechanical room is located off the garage at Elevation 5002.00, the mechanical equipment is located 4 feet above the floor at Elevation 5006.00. here if SECTION E -BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zones AO and A (without BFE), complete Items El-E5. If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A, B, and C. For Items El-E4, use natural grade, If available. Check the measurement used. In Puerto Rico only, enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement, crawl space, or enclosure) is _ _ ❑ feet ❑ meters ❑ above or ❑ below the HAG. b) Top of bottom floor (including basement, crawl space, or enclosure) is — _ ❑ feet ❑ meters ❑ above or ❑ below the LAG. E2. For Building Diagrams 6-8 with permanent flood openings provided in Section A Items 8 and/or 9 (see page 8 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is — _ ❑ feet ❑ meters ❑ above or ❑ below the HAG. E3. Attached garage (top of slab) is _ _ ❑ feet ❑ meters ❑ above or ❑ below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is — _ ❑ feet ❑ meters ❑ above or ❑ below the HAG. E5. Zane AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION 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. The statements in Sections A, B, and E are correct to the best of my knowledge. Property Owner's or Owner's Authorized Representative's Name Address City State ZIP Code Signature Date Telephone ❑ Check here lt attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the communitys n000piam management oromance can compiete Ji and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8. and G9. G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. ❑ A community official completed Section E for a building located in Zone A (without a FEMA-issued or community -issued BFE) or Zone AO. G3. ❑ The following information (Items G4.-G9.) is provided for community floodplain management purposes. G4. Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building: _ _ _❑ feet ❑ meters (PR) Datum _ G9. BFE or (in Zone AO) depth of flooding at the building site: []feet ❑ meters (PR) Datum _ Community Name /'12/ Telephone ' Signature .O /1 JM Date &/�� /n-7 A /dAi .n r7 d�/�/ice/ Comments 2-20-200T 16:12 FROM-STEWART AND ASSOC WLS t970 482 9382 AiiR Federal Emergency M6V ATiGM GER r��aCanagement Ayerny ? National Flood insurance Program IMP00111: Read the instructions on pages 1-s. SECTION A -PROPERTY INFORMATION Al. RonAinn A,n..eNs Address Suite, and/or Bldg. NOW Box No. T-526 P.001 F-914 OMB No- 1660-0008 Expires February 28. 2D09 For Insurance Company Use: A4, Building Use (e.g., R een•Resida 1, Addition, Accessory. etc.) .SSrElj�rcY�'<(L.. AS. Latnudell orcgnude' at Larg.� All Attach at least 2 � Horizontal Datum: ❑ AIAD 19ZT d 1983 r PI he Certificate Sheirg"used to atltaIn good Durance. t>j AT. Binding Diagram Number _� A5. For a buip ng with a crawl space or endosure(s), provide rr , ,✓ a) Square foote9e of crawl space or endasure(s) 0 AR. For a building with an attached garage, provfd b) No. of permanent flood apenlrrgs in the cral space or fl a) Square wmanfootage t a*dAttaOPehed garage enclosures) wdns will 1.0 foot above adjacent grade �- bj No. ofpermanent good openkrgs In the a _yore c1 Toot net area of good openings Sn AB.b o waifs within 1.011 above adjacent grade _ sq do c] Total net area of good openings In A9.b L3 sq in SECTION B -FLOOD lN5URANCE RATE MAP (FIRM) INFORMATION B1. NFIP Commun t Name S C,ormm � Num�O 82. County Name e.r Q B3. State �' 84. MapiPdnel. Number 65, Suffix 96_ FIRM Index BT. FIRM Panel B8, Flood B9 Baae Ftood Elevalia'n( js (Zane U FClf_+ C r--� time Effective/Revised Date Zone(aj AO, use base good uepth) ,b f B110. Indicate the source of the Base Flood Elevation (BFE) data or base Good depth entered in Item 89. 00.Z.0 -- O PIS Profile 'FIRM 13 Community Determined 11 Other (Describe) B11. Indicate elevation datum used for BFE in item B9: ❑ 11928 EKNAVD I sea ❑ Other (Describe) B12, Is Designatiothe nanon Date located in a Coastal Barrier Reseutcea System (GBRS) are$ or Otherwise Protected Area (011 ❑Yes CBRS ❑ CPA No D[Jj SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: 0 Construction Drawings' 0 BuildingUreter Construction" 'A new Elevation Carttrrcate will be required when construct on of the bunding is complete. Finished Construction CZ, Elevation$ -Zones A1,430. A$, AH, .a-g A (withBFE), VE, Vf-v30, V (withaFE), AR, AR/A, AR/AE. AR/Al-A30, ARfAH, ARIAO. Ce items C2 below according to the building diagram specified in Item AT, omplet Benchmark Utifized Vertical Datum ConversionrComments Check the measurement used, a) Top of bottom floor (including basement, crawl space, or e,closim floor)_ 6-V .�_� Check b) Top of the next higher floor 0 meters (Puerto Rico only) 0) Bottom Of the lowest horizontal sluctrural member (V Zones only) ZP Ofeet ❑ meters (Puerto Rico only) Q test ❑ meters (Puerto Rico only) d1 Attached garage (top bl stab) IM feat ❑ meters (Puerto Rico orgy) e) Lowest elevation of machinery or equipment servicing the building jai, {y 5111 C3 meters (Puedo Rieo and e l B rr (Describe type of equipment In Comments) _YL-d0 f) Lowest adjacent (finished) grata (LAG) 0_04- .feet d melers (Puerto Ric, only) 9) Highest adjacent (finished) grade (HAG) feet 0 rNttere (Puerto Rico only) � � il 1� �.... ....n+ r+ghc,w acre seated by a land surveyor, engil or ardrdect aumorIzed by law to certify slat information. i carill that the information on this Ced(ffeate raP Ir"ards my best effads to Interpret me data overfable. f understand that any false $fafement may be punishable by8rre erhnprbor mrent under 18 US. Code, Section fool. Check here if comments are provided on back of farm. 5 U.S.DEPARTMENT OFHOMELAND SECURITY ELEVATION CERTIFICATE ' OMB No. 1660OW8 Federal Emergency Management Agency I Exoires February 28.2009 National Flood Insurance Program important: Read the instructions on pages 1-8. SECTION A - PROPERTY INFORMATION For insurance Company Use. Al. Building Owner's Name Jack Number A2. Building Sheet Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. - Company NAIC Number 1941 Wallenberg Drive - Lot 18, Collins State CO ZIP Code 80526 Creek A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.) Residential A5.- Latitude/Longitude: Lat. 40h3348"N Long. 105405'15'VJ Horizontal Datum: ❑ NAD 1927 ❑ NAD 1983 A6. Attach at least 2 photographs of the building If the Certificate is being used to obtain flood insurance. AT Building Diagram Number 1 As. For a building with a crawl space or enclosure(s), provide A9. For a building with an attached garage, provide: a) Square footage of crawl space or enclosure(s) 0 sq ft a) Square footage of attached garage 633 sq ft b) No. of permanent flood openings in the crawl space or b) No. of permanent flood openings in the attached garage enclosure(s) walls within 1.0 foot above adjacent grade 0 walls within 1.0 foot above adjacent grade _I c) Total net area of flood openings in A8.b 0 sq in c) Total net area of flood openings in A9.b 7ZP2. sq in SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION City of Port Collins080102Latimer.__.. 1_CO. B4. Map/Panel Number B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9. Base Flood Elevalion(s) (Zone Date Effective/Revised Data Zone(s) AO, use base flood depth) 080102C0979f F Dec. 19, 2006 October 20, 1998 AE 5002.0 B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9. ❑ FIS Profile ® FIRM ❑ Community Determined ❑ Other (Describe) _ Bl l.. Indicate elevation datum used for BFE in Item 69: ❑ NGVD 1929 ® NAVD 1988 ❑ Other (Describe) B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)7 ❑Yes ®No Designation Date ❑ CBRS ❑ OPA - SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: ❑ Construction Drawings' ❑ Building Under Construction` ® Finished Construction A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations -Zones Al-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA, AR/AE, AR/Al-A30, AR/AH, AR/AO. Complete Items C2.ag below according to the building diagram specified in Item A7. - Benchmark Utilized RM1 EL=5200.6 Vertical Datum NGVD1929 Conversion/Comments - Check the measurement used. a) Top of bottom floor (including basement, crawl space, or enclosure floor)_ 5003.6 ® feet ❑ meters (Puerto Rico only) b) Top of the next higher floor 5013.0 ® feet ❑ meters_ (Puerto, Rico only) c) Bottom of the lowest horizontal structural member (V Zones only) N/A ._ ❑ feet ❑ meters (Puerto Rico only) d) Attached garage (top of slab) 5002.6 ® feet ❑ meters (Puerto Rioo only) e) Lowest elevation of machinery or equipment servicing the building 5006.0 ® feet ❑ meters (Puerto Rico only) (Describe type of equipment in Comments) 0 Lowest adjacent (finished) grade (LAG) 5002.0 ® feet ❑ meters (Puerto Rico only) g) Highest adjacent (finished) grade (HAG) 5003.2 ® feet ❑ meters (Puerto Rico only) - SECTION D-SURVEYOR. ENGINEER_ OR ARCHITECT CFRTIFICATION - - This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify ele% information. l certify that the information on this Certificate represents my best etfoits to interpret the data available. I understand that any false statement may be punishable by fine crimprisonment under 18 U.S. Code, Section 1001. ® Check here if comments are provided on back of form. E. .*5265 6l(4/0-7 __J IMPORTANT: In these spaces copy the corresponding information from Section A. For Insurance Company Use: c,mwn.,. Q..mr Arfrl �Q finrJrrdina Ant.. Unit- Suite_ and/or Bklo. No.) or P.O. Route and Box No. Policy Number 1941 Wallenberg St City Fort Cofins State CO ZIP Code. SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINULU) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent(company, and (3) building owner. Comments 'Benchmark used was City of Ft Colins ACBM#28-92 Elevation = 5007.48. 3 feet was added to our field shots to convert from 1929 Datum to 1988 Datum. The mechanical room is located off the garage at Elevation 5002.00, the mechanical equipment is located 4 feet above the floor at Elevation 5006.00. - SECTION E BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT 91-E) For Zones AO and A (without BFE), Complete Items E1-E5. If the Certificate is intended to support a LOMA or LOMR.F request, complete Sections A, B, and C. For Items El-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement, crawl space, or enclosure) is _ ❑ feet- ❑ meters ❑ above or ❑ below the HAG. b) Top of bottom floor (including basement, crawl space, or enclosure) is _ _ ❑ feet ❑ meters ❑ above or ❑ below the LAG. E2. For Building Diagrams 6-8 with permanent flood openings provided in Section A Items 8 and/or 9 (see page 8 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is —_ ❑ feet ❑ meters ❑ above or ❑ below the HAG. E3. Attached garage (top of slab) is _ ^ ❑ feet ❑ meters ❑ above or ❑ below the HAG E4. Top of platform of machinery and/or equipment servicing the building is _ _ ❑ feet ❑ meters ❑ above or ❑ below the HAG. E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G. . SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION 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. The statements in Sections A, B, and E are correct to the best of my knowledge: Property Owner's or Owner's Authorized Representative's Name State ZIP Code Signature Date Telephone Comments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8. and G9. G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who Is authorized by law to certify elevation-informstion. (indicate the source and -date of #0 elevation date in the Commentsarea below.) G2. ❑ A community official completed Section E for a building located in Zone A (without a FEMA-issued or community -issued BFE) or Zone AO. G3. ❑ The following information (Items G4.-G9.) is provided for community floodplain management purposes. G7. This permit has been issued for. ❑ New Construction ❑ Substantial Improvement G8. Elevation of as-buih lowest floor (including basement) of the building: _ _ j] feet ❑ meters (PR) Datum _ Gg. BFE or (in Zone AO) depth of flooding at the building site: _ _ ❑ feet ❑ meters (PR) Datum Local Official's Name. !' ) Name Telephone Signature W/� i cis .� .J d /: , /�.n `7c7?i , i �, i Date & 19 A 1n -7 02-20-2007 16:12 FROM-STEWART AND ASSOCIATES or +970 482 9382 flora Sae fan A, e and Box N�a. T-520 P.002 For Insurance F-914 ZIP SECTION D COPY both sides of this Elevation Canificate for (1) CommunitY official, (2) inSurarme a nf/e Co111f1pnk tie ompany, and (3) buildlhp owner. 31 Wy .A.�s� Amish is orrdL r-AGy� 544M /�ti�G..fn�»ic8.j �v,ot,• rr5GtlG4.{F,sd Tit Gaaej i�F-FItoM l4tR Z)ATrAr... •.�-•.•r.r, - � f A/D lB rl 156, E-BUILD11MELEm"AFUIFriwmA4rni.m....r.... — r rc JKCu) FOR ZONE AO AND ZONE A (WITHOt1T aFE}am ForZones AO and A (without BFE), complete ROMS EI-E5, if the Certificate is Intended to support a LOMA or LOMR-F request, Complete Sections A, B. and C. For gems E1-E4, use natural grade, if evaRat>)e- Chack the measurement used, In Puerto Rica arty, enter meters. Et. Provide elevation Information for the following and check grade (HAG) and thehe lowest adjacent grade (LAG), the approptiots boxes to Show whether the elevation is above or below the highest adjacent a) Top Of bottom Roar (including basement, Crawl space, or enct"ureI b) Top of bottom floor (Including basement, Crawl ❑feet Q meters above or Q below the HAG EZ For Building Diagrams " with permanent flood ��, enclosure) in fs:,� ❑ feet ❑ meters ❑ above ar p below the LAG. (elevaton C2,b In the Oh-WOMS) of the bull openings provided in Section A Items $ andfor 9 (see page B of Instructions) the next higner Roar E3. Attached garage (top of slab) is _,,,� � Q feet ❑ meters Q above or 1] below the HAG. E4, Top Of Platform Of machinery and/or equipment Q feet E3 meters ❑ above or E3 below the HAG. e9 ip icing the bAdmil Is _,` Q feet 13 meters ❑ above or ❑ below the HAG. ES. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? Q Yes Q No ❑ Unknown, The local official must certify thls information In Section G. Ptoperty owner or owner's authorized representative who completes Seogona A B and E for Zane A (Without a FEMA-issued or community -issued BFE) Of Zone AO must sign here, The sratemanls 117 Sect/oas A, 9. and 6 are carrect to the best of my knowledge. Property Owner's ar Owne(e Authorized Representative's Name -- Address CRY State ZIP Cade "-- Signature Acle Cmn.nnrra _ Telephone • d • - .'ati n sum rAs. oy law et ordinance to administer fie community's floadplain management ordinance can complete Sections A, 9, C (or E), and G of this Elevation Cerlif�ate. Complete the applicable items) and sign below. Check the measurement used In Itemt GO. and GO. G1. ❑ The information in Section C was taken from other documentation that has been signed and Seated by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation infomtalion. (indicate the Source and date of the elevation data in the Comments area hekrw.) G2. ❑ A community official completed Section E for a bulldmg located in Zone A (without a FEMA.issued or CammunRYASSued BFE) or Zone AO. G3' C7 The following information (Items 04: G9,) is provided for community flaodptain management purposes. rp0ae5. Date Certificate Of 37. This permit has been issued for ❑ New Contbueaon [I Substantial improvement 'S. Elevation of Ss-btlig lowest floor (ncluding basement) Of the building; (] feet Q meters (PR) Datum 39. BFE or (in Zane AO) pepih at flaodlrg at the building site: 1' feet ❑ motors (PR) Datum Local Officisi's Neme Title — Commungy Name Telephone •- Signatture Date -- fl Check here if attachments