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<br />--- .. <br />. <br /> <br />-; <br /> <br />UlVIl:S /'ItO. .;JlH.J/-VV-lJ <br /> <br />FEMA OECLARA nON NUMBER <br />~71 - <br />{/- ~ - J"Y <br />PROJECT APPLICATION NUMBER <br />tf} t./ . t:J / ~ <br /> <br />The purpose of this form is to list the damages 'to property and facilities so that inspectors may be appropriately assigned for a <br />formal survey. <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NOTICE OF INTEREST <br />IN APPLYING FOR FEDERAL DISASTER ASSISTANCE <br /> <br />DATE <br /> <br /> <br /> <br />REQUIREMENTS FOR FEDERAL DAMAGE SURVEYS <br /> <br />A. DEBRIS CLEARANCE <br /> <br />F. PUBLIC UTILITY SYSTEMS <br /> <br />.co <br /> <br />o On Public Roads & Streets including ROW <br /> <br />P1l Other Public Property <br /> <br />p(Private Property (When undertaken by <br />local Government forces) <br /> <br />o Structure Demolition <br /> <br />p! Water 0 Storm Drainage <br />C ~ )t Sanitary Sewerage 0 Ught/Power <br />o Other' <br /> <br />B. PROTECTIVE MEASURES <br />o Life and Safety ~ Heal th <br />14 Property ~ Stream/Drainage Channels <br /> <br />C. ROAD SYSTEMS <br /> <br />G'-FACILITIES UNDER CONSTRUCTION <br /> <br />o Public Facilities' <br /> <br />o Private Non-Profit Facilities.. <br /> <br />H. PRIVATE NON-PROFIT FACILITIES.. <br /> <br />o Roads <br />o Bridges <br />o Traffic Control <br /> <br />o Streets <br /> <br />o Educational <br /> <br />o Medical <br /> <br />o Culverts <br /> <br />o Emergency <br /> <br />o Custodial Care <br /> <br />o Other' <br /> <br />o Utility <br /> <br />D. WATER CONTROL FACILITIES <br />C C1( Dikes 0 Levees 0 Dams <br /> <br />I. OTHER (Not in above categories) <br /> <br />co <br /> <br />o Park Facilities <br /> <br />o Drainage Channels <br /> <br />o Irrigation Works <br /> <br />o Recreational Facilities <br /> <br />E. PUBLIC BUILDINGS AND EQUIPMENT <br />o Public Buildings <br /> <br />o Supplies or inventory <br />o Vehicles or other equipment <br />o Transportation Systems <br />o Higher Education Facilities <br /> <br /> <br />* Indicate type of facility. <br />** Provide name of the facility and of private non-profit owner. <br /> <br />NAME OF POLITICAL SUBDIVt510N OR ELIGIBLE APPLICANT <br />1 /;WN ~Y ~'// <br />BUSINESS ADDRESS <br />~J'/ , <br />NAME AND TITLE OF LOCAL CONTACT <br />;,/ ere t& <br />BUSINESS TELEPHONE NUMBER "elude Area Code) <br />4 J03~g'76 - ,2 3.s J <br /> <br /> <br /> <br />HOME TELEPHONE NUMBER (Indude ,Area Code) <br />:SOs. -8.1<..- Sl4c.. ~ <br /> <br />FEMA Form 90-49. MA V 82 <br /> <br />REPLACES EDITION OF MAR 80, WHICH IS OBSOLETE. <br />