Laserfiche WebLink
<br />OG2G26 <br /> <br />STATE OF COLORADO <br />DAMAGE SURVEY REPORT <br />DISASTER RESPONSE AND RECOVERY <br /> <br />3, DECLARATION NO, <br /> <br />9, DESCRIPTION OF DAMAGE <br />FLa:,() Fid.;lr EFFaers <br />'rSSkI/i&-E LA~<Xl1VS <br /> <br />1, TO COLORADO DIVISION OF DISASTER EMERGENCY SERVICES <br /> <br />;-:';~CZloFAg.nBCetCit~rbIt.TE' : PA NO, <br /> <br />7. ~K CATEGORY ("X"~P licable Box) DSR NO. <br />~ERGENCY 0 A : CO 10 <br />o PERMANENT 0 C DOE 0 FOG 0 H 0 I I - <br />8. DAMAGED FACILITIES (Location. identification and description) <br />Iu/JTe.e POA./{)S, SE.W,t;a.E LA~N5 <br />(1/71/ P/l/2k:.. <br />~ :if, <br /> <br />jilT bO/lrt5e $A.JLJ 5 <br />~,uL> C?/ rf/ 'pA~1:::..... <br /> <br /> <br />5_ <br /> <br /> <br /> <br />o CONTRACT <br />~ORCE ACCOUNT <br /> <br />6, PERCENTAGE OF WORK <br />COMPLETED TO DATE <br /> <br />..5l % <br />SA. FACILITY IN OR AFFECTS <br />FLOOD PLAIN OR WET LANDS <br /> <br />~YES 0 NO <br /> <br />10. SCOPE OF PROPOSED WORK <br /> <br />thnty- ~f~~ <br />dt:l/J1afe~ bY F/OOO <br /> <br />~/v~,./s/ tfr~/k <br />tv A 7E~..s <br /> <br />OF /It?ee <br /> <br />ca Ate :s <br /> <br /> <br />UNIT <br />{bl <br /> <br />11. ESTIMATED COST OF PROPOSED WORK <br />MATERIAL ANDIOR DESCRIPTION UNIT PRICE <br />5 ~ ~ <br /> <br />COST (dollard <br />leI <br /> <br />: <br /> <br /> <br />lof <br /> <br />IGof <br /> <br /> <br />J' 33 <br /> <br />~. <br /> <br />5Z- <br /> <br />L.. :!>. <br /> <br />16, <br /> <br />lEVI EW (Signature, Agency. dare) <br /> <br />TOTAL" <br /> <br />E IGISLE ATTACHMENTS <br />YES 0 NO <br />o CUR ATTACHMENTS <br />DYES 0 NO <br />CONCUR ATTACHMENTS <br />DYESD NO <br />QEVI EW Onitials and date) <br /> <br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENTATIVE (Signature, Agency, date) <br />