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Home My WebLink AboutBLD2013-00152 Flood Certificate • I 4��°N �� JEFFERSON COUNTY ;i r� r Imo, _ , DEPARTMENT OF COMMUNITY DEVELOPMENT ' 7 L � — v -� I, -N s..,.? 10 fre---'-.:-:..... 621 Sheridan Street • Port Townsend • Washington 98368 i f.', ;, I LL!i3 O 360/379-4450 • 360/379-4451 Fax �`�$INO� http://www.co.jefferson.wa.us/commdevelopment/ 1 JEFFERSON COUNTY __ _DFPT_OF COMMUNITY DEVELOPMENT Stormwater Calculation Worksheet MLA# PROJECT/APPLICANT NAME: DETERMINING STORMWATER MANAGEMENT REQUIREMENTS: This stormwater calculation worksheet should be completed first to classify the proposal as "small,""medium," or"large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE (I.E.,SITE) Size of parcel acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover (both vegetative and non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing, grading, filling, excavation, and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds, that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir,western hemlock,western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry, and salal; herbaceous plants such as sword fern, foam flower, and fireweed. LAND DISTURBING ACTIVITY, CONVERSION OF NATIVE VEGETATION, AND VOLUME OF CUT/FILL Calculate the total area to be cleared, graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Construction site for structures L Does the project convert 3 acres or more of .7& sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank, etc. sq/ft Circle: Yes No Well, utilities, etc. sq/ft Does the project convert 2 1/z acres or more of native vegetation to pasture? Driveway, parking, roads, etc. sq/ft Circle: Yes No Lawn, landscaping, etc. sq/ft Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance 1.16 sq/ft Cut Fill (cu/yd) [over] stormwater calc worksheet Rev 9-9-2010—REV 9/9/2010 1 I • Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops, walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving, gravel roads, packed earthen materials, and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater. STORMWATER CALULATIONS—IMPERVIOUS SURFACE NEW EXISTING Structures(all roof area) 116' sq/ft Structures (all roof area) I45-D sq/ft Sidewalks sq/ft Sidewalks sq/ft Patios sq/ft Patios sq/ft Solid Decks sq/ft Solid Decks sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads, etc sq/ft Driveway, parking, roads, etc / go` sq/ft Other sq/ft Other sq/ft Total New I 110 _sq/ft Total Existing 4'76 7 sq/ft TOTAL NEW+TOTAL EXISTING* q`l 7 sq/ft *This amount will be used BY STAFF to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: cyo Does the site have 35%or more of existing impervious surface? Circle: Yes No FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of"medium" projects—those that must meet only Minimum Requirements #1 through #5—and for "large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation Worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owner .f th affected pri perty. A _1, ., , _ J - f3 (LAN0• RORAUTHORZEIREPRESENTATIVESIGNATURE) ( ATE) FOR •FFICE USE ONLY SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No stormwater calc worksheet Rev 9-9-2010—REV 9/9/2010 2 U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE FEDERAL EMERGENCY MANAGEMENT AGENCY OMB No. 1660-0008 National Flood Insurance Program Important: Read the instructions on pages 1-9. Expiration Date: July 31, 2015 SECTION A-PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Oscar Tuazon Policy Number: A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg. No.)or P.O.Route and Box No. Company NAIC Number: 1099 Oil City Road(Cougar Glen Road-Hoh River) City Forks State WA ZIP Code 98331 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) Lot 10 Vol. 10 Pg. 143-Surveys; Parcel#612041008; Por.Gvt. Lt.6 Sec.4,T26N,RI2W,W.M.Jef.Co A4. Building Use(e.g., Residential,Non-Residential,Addition,Accessory,etc.) Rainwater Harvesting Tank Pad A5. Latitude/Longitude:Lat.47 deg.47.346' Long. 124 deg.15.854' Horizontal Datum: El NAD 1927 ® NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number NA A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawispace or enclosure(s) NA sq ft a) Square footage of attached garage NA sq ft b) Number of permanent flood openings in the crawispace b) Number of permanent flood openings in the attached garage or enclosure(s)within 1.0 foot above adjacent grade NA within 1.0 foot above adjacent grade NA c) Total net area of flood openings in A8.b NA sq in c) Total net area of flood openings in A9.b NA sq in d) Engineered flood openings? ❑ Yes ® No d) Engineered flood openings? El Yes Z No SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1.NFIP Community Name&Community Number B2.County Name B3. State Unincorporated Jef.Co.530069 0575 575 Jefferson Washington B4.Map/Panel Number B5.Suffix B6. FIRM Index Date B7. FIRM Panel B8. Flood B9 Base Flood Elevation(s)(Zone 530069 0575 B 7/19/82 Effective/Revised Date Zone(s) AO,use base flood depth) 7/19/82 A 159.4'-164.9" B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9. ❑ FIS Profile ❑ FIRM ❑ Community Determined Z Other/Source:WSDOT by Herrera E.C.7/04 B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ® NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? El Yes ® No Designation Date: ❑ CBRS ❑ OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1. 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,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO.Complete Items C2.a-h below according to the building diagram specified in Item A7. In Puerto Rico only,enter meters. Benchmark Utilized:Y-473-1974 Vertical Datum: 186.95'NGS-NAVD88 Indicate elevation datum used for the elevations in items a)through h)below. ❑ NGVD 1929 El NAVD 1988 0 Other/Source: Datum used for building elevations must be the same as that used for the BFE. Check the measurement used. a) Top of bottom floor(including basement,crawlspace,or enclosure floor) NA. ❑feet ❑meters b) Top of the next higher floor NA. ❑feet ❑meters c) Bottom of the lowest horizontal structural member(V Zones only) NA. ❑feet ❑meters d)Attached garage(top of slab) NA. ❑feet ❑meters e) Lowest elevation of machinery or equipment servicing the building NA. ❑feet El meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) **169.74 ®feet ❑meters g) Highest adjacent(finished)grade next to building(HAG) "171.16 ®feet El meters h) Lowest adjacent grade at lowest elevation of deck or stairs,including structural support NA. ❑feet ❑meters 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 certify elevation 1 �. information.I certify that the information 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. El y;i (' Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a • ryx , %ty CI ® r • 3 Check here if attachments. licensed land surveyor? Yes ❑ No 1 'c. I -3 rF Certifier's Name Dan P. Kousbaugh License Number RLS 11983 Title President Company Name Dan Kousbaugh Surveying, Inc.,P.S. dzsi• � Address 450 Spruce Drive City Forks State WA ZIP Code 98331 Signature --`a pi,iyajhuete 5/23/13 Telephone (360)374-5720 C/Z3/i3 ELEVATION CERTIFICATE, page 2 IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt.,Unit,Suite,and/or Bldg. No.)or P.O.Route and Box No. Policy Number: 1099 Oil City Road(Cougar Glen Road-Hoh River City Forks State WA ZIP Code 98331 Company NAIC Number: SECTION D—SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner. Comments **Denotes undisturbed ground elevations in area where base pad will be constructed for potable rainwater harvesting system. 100 year flood elevations were determined for WSDOT by Herrera Environmental Consultants in 7/04. In this area covered by cross sections#60,#70,#80&#90 the 100 year flood level was set at 159.4', 160.7', 162.0'and 164.9'respectively. Undisturbed ground levels range from 169.74'to 171.16'where the concrete base pad will be set.Signature n� Date 5/23/13 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. El. 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,crawlspace,or enclosure)is NA. ❑feet El meters ❑above or❑below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is NA._ ❑feet El meters ❑above or❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor (elevation C2.b in the diagrams)of the building is NA. ❑feet ❑meters El above or ❑below the HAG. E3. Attached garage(top of slab)is NA. ❑feet ❑meters ❑above or ❑below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is NA. ❑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 Dan P. Kousbaugh Address 450 Spruce Drive City City Forks State WA ZIP Code 98331 Signature a ,1 � Date 5/23/13 Telephone (360)374-5720 Comments Flooror of existing home at this site 171. and base pad area 169.74'-171.16'is above 100 year flood level of 159.4'to 164.9'. ❑Check here if attachments. 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—G10. In Puerto Rico only,enter meters. 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—G10)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 Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters Datum G10. Community's design flood elevation: ❑feet ❑meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑Check here if attachments. 0' U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE FEDERAL EMERGENCY MANAGEMENT AGENCY OMB No. 1660-0008 National Flood Insurance Program important: Read the instructions on pages 1-9. Expiration Date:July 31, 2015 SECTION A-PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Oscar Tuazon Policy Number: A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number: 1099 Oil City Road(Cougar Glen Road-Hoh River) City Forks State WA ZIP Code 98331 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) Lot 10 Vol.10 Pg.143-Surveys; Parcel#612041008;Por.Gvt.Lt.6 Sec.4,T26N,R12W,W.M.Jef.Co A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Rainwater Harvesting Tank Pad A5. Latitude/Longitude.Lat.47 deg.47.346' Long.124 deg.15.854 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. A7. Building Diagram Number NA A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) NA sq ft a) Square footage of attached garage NA sq ft b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage or enclosure(s)within 1.0 foot above adjacent grade NA within 1.0 foot above adjacent grade NA c) Total net area of flood openings in A8.b NA sq in c) Total net area of flood openings in A9.b NA sq in d) Engineered flood openings? 0 Yes ® No d) Engineered flood openings? ❑ Yes El No SECTION B—FLOOD INSURANCE RATE MAP(FIRM)INFORMATION Bt.NFIP Community Name&Community Number B2.County Name B3.State Unincorporated Jef.Co.530069 0575 575 Jefferson Washington B4.Map/Panel Number B5_Suffix B6.FIRM Index Date B7.FIRM Panel B8.Flood B9 Base Flood Elevation(s)(Zone 530069 0575 B 7/19/82 Effective/Revised Date Zone(s) AO,use base flood depth) 7/19/82 A 159.4.-164.9" 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/Source:WSDOT by Herrera E.C.7/04 B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ® NAVD 1988 ❑ Other/Source: _ B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? 0 Yes ® No Designation Date: ❑ CBRS ❑ OPA SECTION C—BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) Cl. Building elevations are based on: ® Construction Drawings' 0 Building Under Construction' 0 Finished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A1—A30,AE,AH,A(with BFE),VE,V1—V30,V(with BFE),AR,AR/A,AR/AE,AR/A1—A30,AR/AH,AR/AO.Complete Items C2.a—h below according to the building diagram specified in Item A7.In Puerto Rico only,enter meters. Benchmark Utilized:Y-473-1974 Vertical Datum: 186,95'NGS-NAVD88 Indicate elevation datum used for the elevations in items a)through h)below. NGVD 1929 ®NAVD 1988 0 Other/Source Datum used for building elevations must be the same as that used for the BFE Check the measurement used. a)Top of bottom floor(including basement,crawlspace,or enclosure floor) NA. 0 feet 0 meters b)Top of the next higher floor NA. 0 feet 0 meters c) Bottom of the lowest horizontal structural member(V Zones only) NA. _ 0 feet 0 meters d)Attached garage(top of slab) NA. ❑feet 0 meters e) Lowest elevation of machinery or equipment servicing the building NA. 0 feet 0 meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) "169 74 ®feet ❑meters g) Highest adjacent(finished)grade next to building(HAG) "171.16 ®feet 0 meters h) Lowest adjacent grade at lowest elevation of deck or stairs,including structural support NA. 0 feet 0 meters SECTION D—SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION r This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation r information./certify that the information on this Certificate represents my best efforts to interpret the data available. `l •' "" •::: I understand that any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001. ' "'`' ;•.' , j ® Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a j 0 Check here if attachments. licensed land surveyor'? ® Yes 0 No ) Certifiers Name Dan P.Kousbaugh License Number R LS 11983 S,�, '` T,^11.�J pit:'./4 j4 Title President Company Name Dan Kousbaugh Surveying,Inc.,P.S. di5.�'y='I f �•`� Address 450DA/ Spruce Drive City Forks State WA ZIP Code 98331 SAL L'1 s Signature �} /� 4, ate 5/23/13 Telephone (360)374-5720 ,�Y ,cfl �yf�1J�1 ` • t YI, !/�lv,/......l(:J/.J M10 r 6723/13 ELEVATION CERTIFICATE,page 2 IMPORTANT:In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Policy Number: 1099 Oil City Road(Cougar Glen Road-Hoh River City Forks State WA ZIP Code 98331 Company NAIC Number: SECTION D—SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED) Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner. Comments "Denotes undisturbed ground elevations in area where base pad will be constructed for potable rainwater harvesting system. 100 year flood elevations were determined for WSDOT by Herrera Environmental Consultants in 7/04. In this area covered by cross sections#60,#70,#80&#90 the 100 year flood level was set at 159.4',160.7',162.0'and 164.9'respectively. Undisturbed ground levels range from 169.74'to 171.16'where the concrete base pad will be set. /� Signature j /J 7F ► (7 Date 5/23/13 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. El. 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,crawlspace,or enclosure)is NA. 0 feet ❑meters ❑above or❑below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is NA. 0 feet 0 meters ❑above or❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor (elevation C2.b in the diagrams)of the building is NA.__ 0 feet 0 meters ❑above or 0 below the HAG. E3. Attached garage(top of slab)is NA. ❑feet ❑meters ❑above or 0 below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is NA. 0 feet 0 meters 0 above or 0 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 0 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 Dan P.Kousbaugh Address 450 Spruce Drive City Forks State WA ZIP Code 98331 • Signature Date 5123/13 Telephone (360)374-5720 'Comments Floor of existing home at this site 171. and base pad area 169.74'-171.16'is above 100 year flood level of 159.4'to 164.9'. ❑Check here if attachments. 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—G10.In Puerto Rico only,enter meters. 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—G10)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 0 meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters Datum G10.Community's design flood elevation: 0 feet ❑meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑Check here if attachments. Fi---„ _________________i o:r v ui \ ) U.S. DEPARTMENT OF HOMELAND SECURITY \ OMB No. 1660-0008 Federal Emergency Management Agency 2 7 201e 1 Expiration Date: November 30, 2018 National Flood Insurance Program )FC iI ELEVATIONSLE. TIfi E Important: Follow the instrLct)oh§b $4 hi'page . { f FrT.r . - Copy all pages of this Elevation Certificate and all attachment's-fa(1)community official, (2)insurance agent/company, and (3)building owner. SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Policy Number: Oscar Tuazon A2. Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Company NAIC Number Box No. 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Forks Washington 98331 A3. Property Description (Lot and Block Numbers,Tax Parcel Number, Legal Description, etc.) Lot 10 Vol. 10 Pg. 143-Surveys: Parcel#612041008; Portion Gvt. Lt. 6 Sec.4, T26N, R12W,W.M., Jefferson County,WA A4. Building Use(e.g., Residential, Non-Residential, Addition,Accessory, etc.) Rainwater Harvesting Tank Concrete Pad A5. Latitude/Longitude: Lat.47 deg 47.346' Long.124 deg 15.854' Horizontal Datum: ❑ NAD 1927 ❑x NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number NA A8. For a building with a crawlspace or enclosure(s): a) Square footage of crawlspace or enclosure(s) 0 sq ft b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade 0 c) Total net area of flood openings in A8.b 0 sq in d) Engineered flood openings? ❑Yes 0 No A9. For a building with an attached garage: a) Square footage of attached garage 0 sq ft b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade 0 c) Total net area of flood openings in A9.b 0 sq in d) Engineered flood openings? ❑ Yes ❑x No SECTION B—FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1. NFIP Community Name&Community Number 82. County Name B3. State Unincorp.Jefferson County 530069 0575 B Jefferson Washington (>I B4. Map/Panel B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood Zone(s) B9. Base Flood Elevation(s) Number Date Effective/ (Zone AO, use Base Revised Date Flood Depth) "'" 575 of 1625 B 07/19/1982 07/19/1982 A 159.4'- 164.9' 8 B10. Indicate the source of the Base Flood Elevation (BFE)data or base flood depth entered in Item B9: ❑ FIS Profile ❑ FIRM ❑ Community Determined x❑ Other/Source: WSDOT by Herrera E.C. 7/04 C. B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ❑x NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System (GBRS)area or Otherwise Protected Area(OPA)? ❑ Yes ❑x No =-',- Designation Date: ❑ CBRS ❑ OPA FEMA Form 086-0-33 (7/15) Replaces all previous editions. Form Page 1 of 6 ' OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30, 2018 IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number: 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Company NAIC Number Forks Washington 98331 SECTION C—BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction* x❑ Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A1—A30,AE,AH,A(with BFE),VE,V1—V30,V(with BFE), AR, AR/A,AR/AE,AR/A1—A30,AR/AH,AR/AO. Complete Items C2.a—h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters. Benchmark Utilized: Y-473-1974 Vertical Datum: 186.95'NGS-NAVD88 Indicate elevation datum used for the elevations in items a)through h) below. ❑ NGVD 1929 0 NAVD 1988 ❑ Other/Source: Datum used for building elevations must be the same as that used for the BFE. Check the measurement used. a) Top of bottom floor(including basement, crawlspace, or enclosure floor) 171. 33 x❑ feet ❑ meters b) Top of the next higher floor N/A. 0 feet ❑ meters c) Bottom of the lowest horizontal structural member(V Zones only) N/A. ❑x feet ❑ meters d) Attached garage(top of slab) NSA. 0 feet ❑ meters e) Lowest elevation of machinery or equipment servicing the building 171. 33 x❑ feet ❑ meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished) grade next to building (LAG) 170, 66 0 feet ❑ meters g) Highest adjacent(finished)grade next to building(HAG) 171. 29 0 feet ❑ meters h) Lowest adjacent grade at lowest elevation of deck or stairs, including NSA. x❑ feet ❑ meters structural support 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 certify 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 may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. r Were latitude and longitude in Section A provided by a licensed land surveyor? 0 Yes ❑No 0 Check here if attachments. , Certifier's Name License Number i�a„d,'- «rr° : :""E"1=74 " :_ / Dan P. Kousbaugh RLS 11983 � KCDU,St. N Title ;t r) �';,,y=`y, President Cyr t t r, '�""� i Company Name .� i:.3 �`~4 t 4 Dan Kousbaugh Surveying, Inc., P. S. fy;✓ k': Address i ,•1'' rr st ool 4-�� '} 450 Spruce Drive �4 4J LA�t .w-?' City State ZIP Code J3 Forks Washington 98331 ." , ' Signat re , •' Date Telephone ZC 1(�,, /, 12/13/2016 (360) 374-5720 /` f , LL.7 i,..,„, „.• Copy all pages of this Elevation Certificate and al(attachments for(1)community official, (2)insurance agent/company, and(3)building owner. Comments(including type of equipment and to ation, per C2(e), if applicable) 171.33'is the average elevation taken from 4 shots on the concrete pad established for a potable rainwater harvesting system. 100 year flood levels were determined for WSDOT by Herrera Environmental Consultants in 7/04. In this area covered by cross sections#60,#70 #80 and#90 the 100 year flood levels was set at 159.4', 160.7', 162.0'and 164.9'respectively. As shown above the concrete base pad for the potable rainwater harvesting tank at an elevation of 171.33' is set well above any calculated base flood elevations. FEMA Form 086-0-33 (7/15) Replaces all previous editions. Form Page 2 of 6 i OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30, 2018 IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number: 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Company NAIC Number Forks Washington 98331 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. El. 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, crawlspace, or enclosure)is 0 04 ❑x feet ❑meters ❑x above or ❑below the HAG. b) Top of bottom floor(including basement, crawlspace, or enclosure)is 0 67 0 feet ❑meters ❑x above or ❑below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 1-2 of Instructions), the next higher floor(elevation C2.b in the diagrams)of the building is N/A. 0 feet ❑meters ❑above or ❑below the HAG. E3. Attached garage(top of slab) is N/A. ❑x feet ❑meters ❑above or ❑below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is 0 04 0 feet ❑meters ❑x 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 or Owner's Authorized Representative's Name Dan P. Kousbaugh Address City State ZIP Code 450 Spruce Drive Forks Washington 98331 Signat re 1 / Date Telephone 12/13/2016 (360)374-5720 Coments ( , The concrete pad for the potable rainwater harvestirig system has an average floor elevation of 171.33'. This elevation is above the determined 100 year flood elevations of 159.4', 160.7', 162.0'and 164.9'established by Herrera Environmental Consultants for WSDOT in 7/04. j Check here if attachments. FEMA Form 086-0-33(7/15) Replaces all previous editions. Form Page 3 of 6 OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30, 2018 IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number: 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Company NAIC Number Forks Washington 98331 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—G10. In Puerto Rico only, enter meters. 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—G10) 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 Limeters Datum • G9. BFE or(in Zone AO)depth of flooding at the building site: ❑ feet ❑ meters Datum G10. Community's design flood elevation: ❑feet ❑ meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments(including type of equipment and location, per C2(e), if applicable) X❑ Check here if attachments. FEMA Form 086-0-33 (7/15) Replaces all previous editions. Form Page 4 of 6 1 I 1 I \, 1 \------\ 1 \� I W oi \ N.) ) (-,,,. z N N O N co N N 1p 3 3Ag^m O F 3 R g too o _ _O a al aa�s .. 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