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<br />OMB No, 3067-0033 <br /> <br />FEMA DECLARATION NUMBER G <br />-?17-/JR- <". <br />OAT <br />tJ~~ v.iT .;J. <br />PROJECT APPLICATION NU BER <br />ON' -0 <br />The purpose of this form is to list thetdamages to property and facilities so that inspectors may be appropriately assigned for a <br />formal survey. <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br /> <br />/'7 61 <br /> <br />NOTICE OF INTEREST <br />IN APPLYING FOR FEDERAL DISASTER ASSISTANCE <br /> <br /> <br />REQUIREMENTS FOR FEDERAL DAMAGE SURVEYS <br /> <br />cP <br /> <br />A. DEBRIS CLEARANCE <br /> <br />~ On Public Roads & Streets including ROW <br /> <br />t'Q Other Public Property <br /> <br />~ Private Property (When undertaken by <br />local Government forces) <br /> <br />o Structure Demolition <br /> <br />COc- <br />-;;---- <br /> <br />F. PUBLIC UTILITY SYSTEMS <br />,M Water 0 Storm Drainage <br />o Sanitary Sewerage 0 Ught/Power <br />o Other. <br /> <br />B. PROTECTIVE MEASURES <br />~ Life and Safety 0 Health <br /> <br />G. FACILmES UNDER CONSTRUCTION <br /> <br />co <br /> <br />o Public Facilities' <br /> <br />o Property <br /> <br />o Stream/Drainage Channels <br /> <br />o Private Non-Profit Facilities.. <br /> <br />C. ROAD SYSTEMS <br /> <br />H. PRIVATE NON-PROFIT FACILITIES" <br /> <br />o Roads <br /> <br />o Streets <br /> <br />o Educational <br /> <br />o Medical <br /> <br />o Bridges <br />o Traffic Control <br /> <br />o Culverts <br /> <br />o Emergency <br />:B Ulili~' ~ 0 <br /> <br />o Custodial Care <br /> <br />o Other' <br /> <br />D. WATER CONTROL FACILITIES <br /> <br />,hi Dikes <br /> <br />~ Levees <br /> <br />o Dams <br /> <br />I. OTHER (Not in above categories) <br />o Park Facilities <br /> <br />c <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 equipmenl <br />o Transportation Systems <br />o Higher Education Facilities <br /> <br />* Indicate type of facility. <br />.. Provide name of the facility and of private non-profit owner. <br /> <br /> <br />7'l. - . _ COUNTY /./ -. S'/; <br />-///S/ /2."lcT 2 ./'-1 C 'T' <br />(-:;,~',r/Yfl Jc.7 ~~ /0 Z~D}-O I <br /> <br />HOME TELEPHONE NUMBER (Include Area Code) <br />..Yc?.:5' -..:<. '0( -J'7 6' <br /> <br />FEMA Form 90-49, MAY 82 <br /> <br />REPLACES EDITION OF MAR 80, WHICH IS OBSOLETE. <br />