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<br />I <br />.. <br />.' ' <br /> <br />CG2u~3 <br /> <br />STATE OF COLORADO <br />DAMAGE SURVEY REPORT <br />DISASTER RESPONSE AND RECOVERY <br /> <br />3, DECLARATION NO, <br /> <br />I, TO COLORADO DIVISION OF DISASTER EMERGENCY SERVICES <br /> <br /> <br />2. APPLICANT (State Agency, County, City, ere.) <br />(] I t7r '/J?t7.sA <br />7. WORK C TEGORY tux" Applicable BoxJ DSR NO. <br />o EMERGENCY 0 0 B : /70';::;- <br />o PERMANENT COD 0 E 0 FOG 0 H 0 I I C' - J <br />8. DAMAGED FACILITIES (Location, identification and description) <br />{!Ot..G ~./U?.l::.t' /l,(NJ S7aRm Sea/e/S. <br /> <br />I PANO. <br />I <br /> <br />'- . ~TRACT <br />~CE ACCOUNT <br /> <br />6. PERCENTAGE OF WORK <br />COMPLETED TO DATE <br /> <br />o % <br />BA. FACILITY IN OR AFFECTS <br />FLOOD PLAIN OR WET LANDS <br /> <br />DYES <br /> <br />ONO <br /> <br />9_ DESCRIPTION OF DAMAGE . <br />{)C/,e//f/t!:- FLo<,O /lS~H~L r ~//t/b rRA~.c:. ~~ <br />hAS a/9/?7.4 ~GZ) LJt/C!: 70 G"MaeG61Ut'~ ' <br /> <br />10. SCOPE OF PROPOSED WORK <br />R.emUV~ dl9m,L/tS~ ,4SPH/l~T, /?RcP/9RE 64Se- <br /> <br />91- ~ /liBv' ,4SP/Ml~-r_( F~A!<:'e /N!,t!n/N7) <br /> <br />QUANTITY <br />1.1 <br /> <br /> <br />UNIT <br />Ibl <br /> <br />11. ESTIMATED COST OF PROPOSED WORK <br />MATERIAL AND/OR DESCRIPTION <br />lei <br /> <br />UNIT PRICE <br />(dl <br />,.; <br /> <br /> <br />/!M) <br /> <br />~ <br /> <br />COST (dollars) <br />Ie} <br />6/ "" <br />z.. <br />/ 00. ~ <br />40.00 <br /> <br />Z.- <br />.s ~ <br />::z- <br /> <br /> <br />dJ <br />- <br /> <br />- <br /> <br />#11 <br />- <br /> <br /> <br />(J() ~ <br /> <br />12. <br /> <br />13, <br /> <br /> <br />TOTAL" $ 5//9. ~ <br /> <br />16, <br /> <br />lEVIEW (Signature. Agency. dare) <br /> <br />.ELJPIBLE <br />~ONO <br />CONCUR <br />DYES 0 NO <br />CONCUR <br />OYESO NO <br />~ EVI EW (Initials and date) <br /> <br />ATTACHMENTS <br /> <br />14. CONCURRENCE IN REPORT BY STATE INSPECTOR (Signature, Agency, date) <br /> <br />ATTACHMENTS <br /> <br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENTATIVE fSignature, Agency, date) <br /> <br />ATTACHMENTS <br />