|
<br />/,,/"
<br />
<br />r-urm A~IJrU\llXl
<br />OMB No 3067.0027
<br />3. DECLARATION NO.
<br />FEMA 7/9. Vd- (c;...
<br />
<br />4. 18j:IJ:~~\TE
<br />
<br />5. WORK A'CCOMPLlSHED BY
<br />
<br />53 CO NTRACT
<br />o FORCE ACCOUNT
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />DAMAGE SURVEY REPORT
<br />
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />1, TO" REGION
<br />
<br />8
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />.
<br />2. APPLICANT (State Agency, County. City. etc.)
<br />
<br />5""''''-'...../tH <-J~ ~ s-+v. n,-,-,"~ 0. );.
<br />7. WORK CATEGORY (UX" Applicable BoxJ
<br />o EMERGENCY 0 A 0 B
<br />CD G. PERMANENT 0 COD 0 E IZl FOG 0 H 0 I
<br />
<br />I PAND.
<br />11, r1<./,..I,r" I ('5',.,>1-" 9 / MI. <
<br />, DSR NO.
<br />I
<br />I
<br />I
<br />
<br />(1 7 1 4 ') 9
<br />'J11.. L
<br />
<br />6, PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />IT]
<br />
<br />IVU %
<br />BA. FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />8. DAMAGED FACI LlTI ES (Location, went/fication and description)
<br />
<br />,[.f'''''1~" .~?n... .......u ,,_ . ...~ .i.
<br />.t1 ro .., ..,..........n
<br />nO(Jlv-,(j..........~~l..-1 ~Z.w( (...IF 12 C~~ ..........-n.">-t
<br />.1___ 'T .y.:: .,..,'. r (A"l.. "'r. ~",....-? 1...,,::::':( <:: L..,"
<br />9. DESCRIPTION OF DAMAGE
<br />
<br />1 'R '( r . , - y
<br />
<br />5'"',t:Ip, "'I
<br />.,-~ 71o'1........S
<br />;
<br />
<br />DYES
<br />
<br />oNO
<br />
<br />f...1'"-'l..::'" I.,......;A-!
<br />
<br />(;,,--~;r,-I-J""""""o c//~~"-A-t:.t-'t3 <<,...UJt"'t=.,..I
<br />
<br />/T
<br />
<br />L~""'..J,('.ot.-
<br />
<br />o c (vt(,,-~O
<br />
<br />~"...~~ f11t-- ',,-e-
<br />
<br />10. SCOPE OF PROPOSEO WORK
<br />
<br />f?t'Y'< ~C
<br />
<br />Ij /1. 1> ",-"'"
<br />
<br />TllItA/SI7C
<br />I f//pc
<br />
<br />'-'\...< " I-J+
<br />
<br />Il ,{ tJvc rl ~ L
<br />
<br />1/1.........
<br />
<br />t? -'c (JJIf)
<br />
<br />/tl-'O
<br />
<br />)'1, ___ '-.;,'/}.t
<br />
<br />(")l.-.)f ,'""",v
<br />
<br />L.,~.:, tJEflUC.T /)lr'-E:/<-E~c..C IN <::OJ, /?Er<Je:e.N
<br />J'.'EAL-I(;"J ?/I~e /'0 Mv/lc 5,rARGc ~OIL.
<br />
<br />DIP
<br />
<br />r -r1Z.... --'SfIE ,oII'E,
<br />
<br />QUANTITY
<br />Isl
<br />
<br />UNIT
<br />(b)
<br />
<br />11, ESTIMATED COST OF PROPOSED WORK
<br />MATERIAL AND/OR DESCRIPTION
<br />(e)
<br />
<br />Co~ n._T L--*,,~d.'" ............"'>-rl,:....,lC~ J
<br />
<br />)0:.' ~ ,.",'" fJ-k,,-,-... .I
<br />.
<br />
<br />UNIT PRICE
<br />Cdl
<br />
<br />COST Idolls,,)
<br />leI
<br />
<br />17....SI4-
<br />.I
<br />
<br />Q/'l,
<br />--.J C'...... 4=-r
<br />'1 t1'l-t-u--
<br />I [")'!tIt
<br />9.1<; F-r
<br />
<br />/I'1....-.-....:..--.T
<br />I'l." O~cr-, b..:F c,..-- f11f>~ (DIP)
<br />
<br />I ~
<br />
<br />..
<br />
<br />17. Jv
<br />1<"2 "'"
<br />1(. 2. <"
<br />
<br />_ :J 1007+
<br />
<br />2-z..J.~O ;<,,.....,..',
<br />II { " t?~",o,
<br />U;IJ,~ ~" ""'A--nb ......r ',,"'''-'4,
<br />fl~ l)Uc.-1 DIP - EA-.JSI TC ( tll. 00// F):J
<br />~(i" t=t~r IO->'.7L.
<br />
<br />/1 ' .
<br />
<br />I q,' &
<br />II.. 1.
<br />
<br />/ '70
<br />
<br />( / /u..d
<br />2. I; "U 7.4-30
<br />
<br />-? .,<-;7~
<br />12, EXISTING':;:::CE (Type) : ~MOUNT ~_ TOTAL" $~ ~ ~. 'f, .
<br />
<br />13. RECOMMENDATION BY FEDERAL INSPECTOR (Signature, Agency, date) ELIGIBLE @] ATTACHMENTS
<br />~~ ,(.)---L.." V ---1 Q YES 0 NO
<br />14. SQNCURRr~C7 I~REPORT BY(STpTE INSPECTOR (Signature. Agency. date) CONCUR ATTACHMENTS
<br />\., . I'J' I-! ;<>-..;/7"I/V>A ~/41=t' G(l YESo NO
<br />15. .,9, NCURRENCE I~~PORT Blf LOCAL 1'lEPRESENtArl\i~ (S.gnaW/e. Agen~y. dar;;;---. CONCUR
<br />-,;!,j'" ~f .-/ /, 5/\1..';",,' JJJA,' ,~......D:J.~. C /< ",'" cUrer ~YESO NO
<br />16.. FE.DERA~ JlEVIEW '!.ignature:~gency: date) /::' r ./, ~ : FEMA REVIEW (Initia/sand date)
<br />C ,/1."" y"L clf1 O//~/J<t. (C(_ q Y IA '\
<br />
<br />ATTACHMENTS
<br />
<br />FEMA Form 90-52, JAN a1(Formerly HUD Form 4841
<br />
|