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<br />OMBNo.3067-0033--- <br /> <br />.., <br /> <br />FEMA DECLARATION NUMBER <br />E/v,' /! _ ~7':.! _ ) 7_ <br />DATE <br />.(".'/--. -'---' ,'--:"; 'V";:, <br />/--; ,.. ......,;, <br />PROJECT APPLICATION NU SE <br />'Z <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 />REQUI REMENTS FOR FEDERAL DAMAGE SURVEYS <br /> <br />A. DEBRIS CLEARANCE <br /> <br />F. PUBLIC UTILITY SYSTEMS <br /> <br />cc <br /> <br />o On Public Roads & Streets including ROW <br /> <br />MOther Publlc Property <br /> <br />o Private Property (When undenaken by <br />local Government forces) <br /> <br />o Structure Demolition <br /> <br />o Water <br /> <br />o Storm Drainage <br /> <br />o Sanitary Sewerage <br />o Other' <br /> <br />OUght/Power <br /> <br />B. PROTECTIVE MEASURES <br /> <br />G. FACILITIES UNDER CONSTRUCTION <br /> <br />o Life and Safety <br /> <br />o Health <br /> <br />o Public Facilities' <br /> <br />o Property <br /> <br />o Stream/Drainage Channels <br /> <br />D Private Non-Profit Facilities.. <br /> <br />C. ROAD SYSTEMS <br />R Roads <br /> <br />H. PRIVATE NON-PROFIT FACILITIES" <br /> <br />o Streets <br /> <br />o Educational <br /> <br />o Medical <br /> <br />r::tlV- ,4- <br />, <br /> <br />o Bridges <br /> <br />~ Culverts <br /> <br />Q;( Other' r;"'/<II '{. <br />L( /~ . <br /> <br />o Emergency <br /> <br />o Custodial Care <br /> <br />o Traffic Control <br /> <br />o Utility <br /> <br />D. WATER CONTROL FACILITIES <br /> <br />('0 <br /> <br />)1(:1 Dikes <br /> <br />o Levees <br /> <br />o Dams <br /> <br />l. OTHER (Not in abol'e categories) <br />L_v2 ~ Park Facilities <br />---- D' Recreational Facilities <br /> <br />o Drainage Channels ;iy Irrigation Works <br /> <br />E. PUBLIC BUILDINGS AND EQUIPMENT <br />,CQPublic Buildings <br />o Supplies or inventory <br /> <br />av' <br /> <br />o Vehicles or other equipment <br />D Transportation Syste~s <br />o Higher Education Facilities <br /> <br />* Indicate type of facility. <br />** Provide name of the (acUity and of private non-profit owner. <br /> <br />NAME OF POLITICAL SUBDIVISION OR ELIGIBLE APPLICANT <br />'~/}J...,/.l-- ....;;, ;t.;;.. '~;Lfi^,'c/ ACe.~~E ..}'''_~1.:' <br />BUSINESS ADDRESS - - ..' ~. A:i 7 " ! _' ~ /:..:- # ,-- '/.c ;... <br />.2:,,_.',#^',r:"'-..'-~(-.S. t,II".' '-~~?,' ':"-~).'-'..r- r;,-....r;:n.(. <br />:t:-"7..:;. t., -''- <br />NA~E ,AN,D TlTL~ o~ LOCAL CONT~CT <br />3 ) /(/,./.1 (', / I.:: 7,/', (- <br />BUSINESS TELEPHONE NUMBER (Include Area Code) <br />4 <.',:'.-: :-.<....V'-~,.,'-;~'..\J <br /> <br />I' ' <br />I~& f:.(i; <br /> <br />FEMA Form 90-49, MA Y 82 <br /> <br />HOME TELEPHONE NUMBER (Includ.e Area Code) <br />.':~'-' ~;\ ,;_J <c - :'''''- <br /> <br />REPLACES EDITION OF MAR 80. WHICH IS OBSOLETE. <br />