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<br />
<br />OMS I'k', 30G 7.0027
<br />3. DECLARATION NO.
<br />FEMA 7/9 /)/<'. ( 0
<br />4, INSPECTION DATE
<br />
<br />FEOERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />1. TO'"
<br />
<br />REGION
<br />
<br />8
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />5. WORK ACCOMPLISHED BY
<br />
<br />
<br />o CONTRACT
<br />J)i:.FORCE ACCOUNT
<br />
<br />2. APPLICANT (Stare Agency, County, City, ere.) PA NO.
<br />__._.....l1o..HA f C OV"'4_~ : nj'fJ.!-=12&o.On
<br />7. WORK CATEGORY ("X" Applicable Box) I OSR ~cr- 6. PERCENTAGE OF WORK
<br />[J EMERGENCY 0 A 0 B I ", Lt. r, .~) ,......, COMPLETED TO DATE
<br />[D.:..~PERMANENTpil.cDD DE.OF DGDH 01 L ,::iL,b I2l %
<br />
<br />8. OM-lAC: ~JLI-r;S;oca;;;,:d:;7:';~;dKescd(;O~ '1. S" ( Co f{ J 3 2. :ra, SA, ~~g~~Tp~j.~NO~RA~~~C:;NDS
<br />
<br />I 0 YES ;)<lNO
<br />
<br />-~-~~-- I'^'o :,Jt'S -Ju~to /11",J.sT:lC~-
<br />115 'L X :<S'H t)ONf./ ONe
<br />
<br />9. DESCRIPTIO" OF DAMAGE I .L I f .1
<br />EI'1 !HI'" kMe", 1 105 /IT
<br />
<br />CfJvseJ br he!'? ,..",,,,,.,{t'
<br />
<br />AH",Js f'-opO
<br />
<br />(
<br />
<br />10, SCOPE Of PROPOSED WORK
<br />
<br />;<r,o~(e knbA~t<MP,J
<br />
<br />G tlp" + - I f'J .j, e v
<br />
<br />1,'
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<br />01. /: I ) c.,,,,Jj
<br />'<~~t
<br />
<br />~4
<br />
<br />,5
<br />
<br />cu,.,~;l'''I2-:N''...
<br />-....)
<br />
<br />
<br />UNIT
<br />
<br />11. ESTIMATED COST OF PROPOSED WORK
<br />MATERIAL-ANDIOR DESCR~PTioN'----- ..-i-----
<br />(e)
<br />
<br />
<br />
<br />.=--~~~_.~L ~~E
<br />- ~t_l-- ~-:--: ----- . -1-=:=:-=-:::
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<br />-=t--t-~~:~---T. .. .._--:....j-.:-+:-_-j-_~. .:---.:
<br />
<br />12, EXISTING INSURANCE !Type! AMOUNT ..
<br />: $ GJ TOTAL S 7 _08<;;
<br />RAL r~J-SP-E-CTon (SilJ{;~-;urf),-A--;;~n~I~. date! ~ - -- ELIGIBLE rn AITACHMENTS---
<br />"'. __L1l...h'..A___~, -2_: 9. g '1----. l,<( YES L'l NO
<br />4ft;. STAT INSPECTO~'""(Sig-'lature, AgcflcV, date) CONCUR ATTACHMENTS
<br />
<br />Cvla_Jh,') -(- J-Iw Vc,_ .-?-9 -If n~ YES[:::!N~ 'A-TT- AC-H-M'ENTS'--'
<br />, T.Al: V Sign'ature Ageru:N. date) , I ;ONCUA
<br />._._.. p/W~YEsDNO
<br />I FEMA RE"rEW-.~:;$ and date)
<br />. -~~;
<br />
<br />//
<br />FEMA Form 90-52, JAN 81(f"ormerly HUn Form 484)
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<br />1
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