HomeMy WebLinkAboutMT-1 Form 2 Elevation Form 11 Elm St - LOMR-F DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.S.NO.1660-0015
ELEVATION FORM Expires February28,2014
PAPERWORK BURDEN DISCLOSURE NOTICE
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,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 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 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),Including an attached deck or garage.For requests to remove an entire 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.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 entirety. Incomplete submissions will
result in processing delays. MA
1. NFIP Community Number: 250001 Property Name or Address: 11 Elm Street, COtu It,
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❑slab on grade R basement/enclosure ❑other(explain)
4. Has DHS-FEMA identified this area as subject to land subsidence or uplift?(see instructions) ❑Yes M No
If yes,what is the date of the current re-leveling? / (month/year)
S. What is the elevation datum?❑NGVD 29 0 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: ❑WGS84 ❑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: ❑WGS84 M NAD83 ❑NAD27 Lat. 41 . 6 0 8 9 Long. 70 .4461
Lowest
Address Lot Number Block Lowest Lot Adjacent Base Flood
BFE Source
Number Elevation* Grade To Elevation
Structure
11 Elm Street-Garage 225 12.3 12.6 10 FIRM
11 Elm Street-House 225 14.4 10 FIRM
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.
Certifier's Name: License No.: Expiration Date:06/30/2022
Thomas J.Bunker,PLS 32653
Company Name: Telephone No.:
BSS Design,Inc. 508-540-8805
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Email: Fax No. ��J-`" •,Ssgc
tom®hssdesion.com 508-548.8313
Signature: Date: A,I A /1 2..L Z4ZZ
_ /_t4�� � THOMAS in
(� JACKSON BUNKER
UNO.32653
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*For requests involving a portion of property,include the lowest ground elevation within `
the metes and bounds description.
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,FEB 11 Elevation Form MT-1 Form 2 Page 1 of 2