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<br />Olv'lB No. 3067-0027
<br />3. DECLARATION NO.
<br />FEMA 7/' I< C' u
<br />4. INSPECTION DATE
<br />- / 1- ,r'l
<br />5. WORK ACCOMPLISHED BY
<br />
<br />o CONTRACT
<br />~ FORCE ACCOUNT
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />,. TO'" REGION .9
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />2, APPLICANT (StiJte Agency; County, CHy; etc. I
<br />
<br />f,'t-J.........6h.~Q..d '7,/"?N"',.S
<br />7. WO K CATEGORY ("X" Applicable Box)
<br />!>c EMERGENCY WAD B
<br />OJ I::::J PERMANENT 0 C ~ D D E 0 F [] G [] H 0 I
<br />-~._----
<br />B. DA1\olAGED FACI LlTI ES (Location. identification and description)
<br />/91-0 ,M,,.IIG ~"" A,,~
<br />
<br />: PA NO.
<br />
<br />: ~:R:-~< ~~_:_'.Z( 1)_____
<br />
<br />I
<br />I
<br />I
<br />
<br />2r~r.9~
<br />'-t:'L b
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />
<br />121 00 %
<br />8A. FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />/I z..4 .....,"J{ t.. Jr,At f: :'~ "" r"~~::_ '" )ooc (....c..-I,..:.."" It )"t' }/)('~~ 0 YES [J NO
<br />9. DESCRIPT:Of\l OF DAMAGE A 'J ..l
<br />n-..LI~ 4"..,1. V~ll{ ,//r~' ""uv( ".... r~ (I1r yo.... . :IT
<br />'1(Jvfr,~" dt.w,.,-y rJ.~ ,~'~.~-<...rp-t'~'O~f ZT","r.5- 4ld.",r
<br />r;"l~t~/yC's/",,,..,.'c;-i~s (~...,T rj..~y yl'..........".......,.J ",6.",,1' /$ooC'r:
<br />
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<br />ISO Ii... 'f '" j.,(
<br />
<br />10. SCOPE OF PROPOSED WORK
<br />
<br />A'l!" ""'<JV~ 1"I1t-1.J"...,.{ '''''fI~,ks
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<br />CQ,. _f;..,..,.l.""_(?/~ r. 1.,.1.
<br />"'...1",_ ,..~~'"I ..I!
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<br />IA.I 11",0 r;r.
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<br />r /l V (;II /1'.> *'" 4" r ~ ""'Clt t '4".; I c. .1...
<br />r( VI<"':'("-..1 4't '1,,..;..1'(",,,;,,,< '.,",
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<br />br1dl'(<' ..cc"...,," -,{.. C",.A" i......O'r I-
<br />
<br />3 e/, II,~"..-r tf'- ~ -/,.,1"$/ 11 ~I'" '(
<br />'.v ,...t' 1t',;jIf..J JIP rj,~ t!st,;"'",t.,
<br />
<br />
<br />11. ESTIMATED COST OF PROPOSED WORK
<br />MATERIAL ANDIOR DESCRIPTION
<br />Ie)
<br />
<br />UNIT PRICE
<br />(d)
<br />
<br />8."11>
<br />
<br />COST (dollars)
<br />Ie)
<br />
<br />'7If~
<br />
<br />I QUANTITY ~UNITI----'-"
<br />lal Il>!
<br />
<br />2,0
<br />
<br />40
<br />
<br />1..'1>. "
<br />
<br />b..*I..~ to~ht!'y
<br />I.
<br />
<br />En<:-
<br />
<br />8. ~O
<br />,. ,r.t::).
<br />I . S-O
<br />
<br />'->::,;;;-' ;;,,;;''', '.~"',.
<br />/70
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<br />lo
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<br />12. EXISTING INSURANCE (Type)
<br />
<br />
<br />13. RECOMMENDATION BY FEDERAL It'JSPECTOR (Signature, Agencv, dar,') I ELIGIBLE ~
<br />~ _ ___----"'C /:1'''''' /I .-.-.--LJ!~.f..,fnll CA;,YES U NO
<br />14. BY STATE INSPECTOR (Sig.?ature, Agency, date) CONCUR
<br />
<br />15. BY AL REPR-E.SEN:/~'!t?~-'~;e.Ag;,~~y:!'e7~-:f$---'3~~~~!!()
<br />'~~,?,rure. AgenCY:_f-LL:-_!d._ 0 YES D NO
<br />
<br />EW (. ignaruU' Agency, datel ~~MA REVIEW (itti~-,s and dare)
<br />~vf/~J'(\~F#/~)4 ~d,w~
<br />F MA Form 90-52, JA 81(Formp.rly HUD Form 484)
<br />
<br />s(~{..
<br />ATTA6:1MENTS---
<br />25At:.
<br />ATTACHMENTS
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