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B-2016-1337CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1337 22024 CREEKSIDE CT CUPERTINO, CA 95014-1103: (326 39 061) ( ALPS CONSTRUCTION & REMODELING INC) SAN JOSE, CA 95129 OWNER'S NAME: ADUSUMILLI VENKATAAND MADALA JAYA S DATE ISSUED: 03/04/2Q 16 OWNER'S PHONE: 408-242-4581 PHONE NO: 408-441-0967 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. #909433 JR Contractor (ALI'S CONSTRUCTION & REMODELING INC) Date 03/04/2016 X BLDG _ELECT —PLUMB — MECH X RESIDENTIAL COMMERCIAL I hereby affirm that I am licensed under the provisions. of Chapter 9 (commencing — with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ADD 209 S.F. SQUARE FEET TO CREATE NEW FOYER, LIVING I hereby affirm under penalty of perjury one of the following two declarations: ROOM, AND GUEST BEDROOM AND BATH 1. 1 have and will maintain a certificate of consent to self -insure for Worker's REV #1 - REPLACE (E) WATER HEATER, (E)FURNACE AND Compensation, as provided for by Section 3700 of the Labor Code, for the UPGRADE MAIN ELECTRICAL PANEL - ISSUED 3/4/2016 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which Sq. Ft Floor Area: 418 Valuation: $130000.00 this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county 326 39 061 Deferred Submittal (R -3),R-3 (Custom) ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code, Section 9.1 Issued by: ABBY AYENDE 'Signature S Date 03/04/2016 Date: 03/04/2016 OWNER -BUILDER DECLARATION RE -ROOFS; I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: 2. I, as owner of the property, am exclusively contracting with licensed Date: 03/04/2016 contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: i. I have and will maintain a Certificate of Consent to self: insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the 14AZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous this permit is issued. material. Additionally, should I use equipment or devices which emit hazardous s. I certify that in the performance of the work for which this permit is issued, I air contaminants defined the. ay a Quality Management District I 'shall not employ any person in any manner so as to become subject to the Cupertino M will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and pl h Worker's Compensation laws of California. If, after making this certificate of the Health & Safety Code, S . 25505, 25533, and 25534. exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall i Owner or authorized agent: be deemed revoked. bate: 03/04/2016 CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Address to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in ARCHITECT'S DECLARATION consequence of the granting of this permit. Additionally, the applicant I understand my plans shall be used as public records. understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date 03/04/2016 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-1337 22024 CREEKSIDE CT CUPERTINO, CA 95014-1103 (326 39 06 1) ALPS CONSTRUCTION & REMODELING INC SAN JOSE, CA 95129 OWNER'S NAME: ADUSUMILLI VENKATAAND MADALA JAYA S DATE ISSUED: 07/15/2016 OWNER'S PHONE: 408-242-4581 PHONE NO: (408) 441-0967 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lie. #909433 ContractorALI'S CONSTRUCTION & REMODELING INC Date 01/31/2018 X BLDG —ELECT _PLUMB I hereby affirm m that I am licensed under the provisions of Chapter 9 (commencing X RESIDENTIAL — _ COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ADD 209 S.F. SQUARE FEET TO CREATE NEW FOYER, LIVING I hereby affirm under penalty of perjury one of the following two declarations: ROOM, AND GUEST BEDROOM AND BATH 1. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. K I have and will maintain Worker's Compensation Insurance, as provided for by f Section 3700 of theLabor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: 209 Valuation: $130000.00 APPLICANT CERTIFICATION certify that i have read this application and state that the above information is correct. I agree to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 326 39 061 R-3 (Custom) representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally, the applicant understands and will comply with all non -point source regulations p r. Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. j Signature LJ Date 07/15/2016 r Issued by: PAUL O'SULLIVAN OWNER -BUILDER DECLARATION Date: 07/15/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) z. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 07/15/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 1 have and will maintain a Certificate of Consent to self -insure for Worker's - Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. i have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall] f' be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date: 07/15/2016 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against sai&City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18, 1 understand my plans shall be used as public records. Licensed SiSignature Date 07/15/2016 9 Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 FAX (408) 777-3333 • building(a)-cupertino.org I—I NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION / DEFERRED ORIGINAL PERMIT # S- wl vb�+ 0 PROTECT ADDRESS') /ii / %/�� �/ v (f�r � L _ APN # 'Mow PHONE q,4 S �2 `7 2 q.5 OWNER NAME ve'A• k +0 t,J> �PIL/ E-MAIL STREET ADDRESS A6 214 C 5 ► �2 J C%� CITY, STATE, ZIPCgp� 1 , O9 C,A FAX CONTACT NAME /I6' PHONE + 0,g bq <1 6 q�'y E-MAIL UZIIP STREET ADDRESS 111 5 V6_R-n� yZl TO CITY, STATE, v� � A 9 -i 151gq FAX ❑ OWNER ❑ OWNIER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMELICENSEENUMBER n/fCOw'�c611s 35 LICENSE TYPE BUS. LIC # COMPANY NAME /;95 � FAX STREET ADDRESS t 5 /1 n 1 YJ b CITY, STATE, zIP5,,, �d� / 2� q F12 C P PHONE ;B� g Lp� L o q f , ! v ARCHITECT/ENGLNEER NAME LICENSE NUMBER BUS. LICC# COMPANY NAME E-h4AII, FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK ap),Jee m rV -30 peVq44 g_ 461' peptic y1(`e gL Tretc,, 10;/ 41 C -&n q0 r3u D USE CONSTR. TYPE EXISTING USE:*REMODEL # STORIES USE TYPE OCC. SQ,FT. VALUATIONS) EXISTG DEMO TOTAL AREA AREA NET AREA BATHROOMN OTHER REMODEL AREA AREA REMODEL AREA PORCH AREA DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: El DETACH I []ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEL\GADDED? []NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS. THE BLDG AN ❑ YES RE. IVED BY TAL VALUATION: PLANNTNGAPPL# ❑NO PLANNING APPROVAL LETTER EICHLERHONIE? No CO By my signature below, I certify to each of the following: I am the property owner or authorized agent tA act on he property owner's behalf, I have read this application and the infomiation I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b d' g onshucti . I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Date: 03 -m 0'i"1 — ,20 1b Signature of Applicant/Agent: Q PL�CHECI�T1�P3ay ?x .,, _ w zROpTIi�G SLIPS , SUPPLEMENTAL INTFORMATION REQUIRED r iS New SFD or Multifamily dwellings: Apply for demolition permit for o� EitTxE COiJtiTER �� �ILDI\G�L91 REUSE«j _ existing building(s). Demolition permit is required prior to issuance of building x permit for: new building. aPtzss PL4\� �Gr�`REc IE�i' fr sT�nARv PUBLicu Commercial Bldgs; Provide a completed Hazardous Materials DisclosureoRis form if any Hazardous Materials are being used as part of this project. s ^_ fl LARGE FIREDEPT Copy of Planning Approval Letter or Meeting with Planning prior to T�L�oxs��ITx� sES� EIZDISTRICT _ submittal of Building Permit application. v BldgApp_201 1. doc revised 06/21/11 CITY OF CUPERTINO h FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 22024 CREEKSIDE CT DATE: 03/04/2016 , REVIEWED BY: ABBY APN: 326 39 061 BP#: B-2016-1337 `VALUATION: 1$5,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex i PENTAMATION PERMIT TYPE: 1 REAP2 WORK REV #1 - REPLACE E WATER HEATER E FURNACE AND UPGRADE MAIN ELECTRICAL SCOPE PANEL Mech. Plan Check 0.0 1 hrs $0.00 Plumb. Plan Check 1 0.0 1 hrs $0.00 Elec. Plan Check I 0.0 hrs $0.00 Mech. Permit Fee: IMPERMIT Plumb. Permit Fee: IPPEPMIT Elec. Permit Fee: IEPERMIT Other Mech. Insp. 0.0 �s$48.00 Other Plumb Insp. 0.0 hrs $48.00 Other Elec. Insp.0.0 hrs $48.00 NOTE. This estimate does not include -fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District etc.). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l in o. FEE ITEMS I ee .Rcsalution 11-053 ,Lf. 7111/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 200 amps $48.00 Electrical IBELEC200 Services i Suppl. PC Fee: 0 Reg. 0 OT0.0 hrs $0.00 PME Plan Check: $0.00 1 1 1# $143,0011 Mechanical Furnace, Forced -Air Permit Fee: $0,00 Suppl. Insp. Fec. Reg. ® OT El hrs $0.00 l ' I # Plumbing $29.00 1PRWHEATR Water Heater PME Unit Fee: $0.00 PME Permit Fee: $144.00 Administrative Fee:: 1ADMIN $45.00 Work Without Permit?0 Yes j No $0.00 Advanced. Pjann n Fee:$0.00 Select a Non -Residential Building or Structure A Travel Documentation Fee:' 1TRAVDOC $48.00 Strong Motion Fee,: IBSEISMICR $0.65 Select all Administrative. Item Bldg Stds Commission Fee: IBCBSC $1.00 ` ; UBTOTALS. $238.65 $220.00 TaTAL FEE: $458.65 Revised: 01/01/2016 Building Department City Of CUpertinc 10300 Terre Avenue Cupertino, CA 9?014-3255 Telephone: 409-777-3228 Fax: 408-777-3333 — .... - ...... ..._._.............. _ 1*0 ADDRESS: 22n2y Gree, side i PERMITi, 20gb - 13� 0MINER'S `�A II �V�,r1� .._�d�St�'�ll F GENERAL C<)1`IR:it;TCalf. AYISupgyu�[�__...t!2Y'1tE3t.15]'1F�i LICENSE ADDRESS: i0((S' pe- AnZa plv • an UW, CAA ! CI"ITWZIPCODE: �5 "Clear municipal rnrle requiresall businesses worldng in the city to have as Cite of Cupertino business license. O BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE.. I arra not easing Fairs' saabeontractors: Signature Date .Please check applicable subcontractors actors Fand complete the following information: ---.................._..............._....__.._._.__...................__..............._.........._ e� 'UB 'ONTRAUJOR BUSINESS i0ANIE __ _ BUSINESS LICENSE Cabinets & Millwork nt Finishin Cement ..................... ...»..............._»...-..»............................... __._................. Electrical Excavation Fencing ............ _..................... _.__.............. _........... -....... -.... ..... _ ................ ._ . _........... Flooring"Carpetiing _—_.._......_........... ................ Linoleum l Wood Glass / Glazing Heating Insulation metAli' �J Landscaping; }Lathing Masonry Painting i Wallpaper Paving; Plastering Plumbing - Septic Tank Sheet Metal Sheet Rock _---- _......... __._... Tile .. . . . ................... Owner 1 Ctara » .arar Sigiaature Cp f 301( --:v Date V17 Venkeita Adusumill! A4, Building Use .(e.gi,Residential, Non=Residentlal, Addition, Accessory, etc,}: desl=01101 A5. Latitude/Longitude: Lat.=JHA[1121--Long. 122MT-15-1 . .......... Horizontal Datum; NAD 1927 N NAD 1983 A6. Attachatleast 2 photographs of the balding if the Certificate is being used to obtainflood insurance: A7. Building Diagram Number q AB. Fora building with aorawlspace or enclosure(s); Aq. For a building With an attached garago:, 6) Square footage of crawlspace enclosures)or-1,- 2352sq-f; a) Square footage of attached garage 43-5 sq ft b) Number ref permanon 'flood openings in. the orawlspqco, umberof permanent flood openings in the attached garage or enclo'Ure(s) within 27 �2 1.0 foot above Within 1.0 fbot, ove aOl' grade . .... adj.acent grade qb acent 1 - c) Total. net area of'food Openings in A&b sq in 6), Total net area of flood openings in AM IA0 sq in d) Engineered flood openings? [] Yes SNo d) Engineered flood openings? Yes, ®No 13j,C.indicate toe source oftha-Basb Flood Elevation (BFE)-d6ta or base flood depth entered In Item 89' 0 P18 Profile [9 FIRM OCommunity Determined Other/Sobrae, 1111. Indicate elevation daturn,used for BFE in Item B9' ON GVD 192a NAVD 1988 1312.11a the, building loetitod in a Coastal Barrier Resources -System (CBRS) area or Otherviise Protected Area (CPA}? MYes ONO Designation Dat,67, —I CBR S 0 CPA C1. Building elevations are based on! M Construction Drawings* Building Under Construction* 0 Finished Constructon :*A newElevationcertificate will be required when construction of the building is complete. Elevations - Zattes AI -Mi AE, A9FE), H, A (With VE, V1430,V (with BM), AR, ARM, ARME, ARIA17480,. AR/Mi ARIAQ. Corn pfete Reins. I ,Ma - h Oel6vaccording.to the building diagram specified in item A7. In Puerto RIPq only, q rVp6r meters. Benchmark Utilized-. SCVW-b Beamark SM400 Vertical Datum: Indicate alevatiandatum used for the elevations in liems a) through h) below. ONbvDig2a MNAVDi988 []Other/So.urcq:,, Datumused for building elevations must be the same as that used for the SFE. Checkthe measurement used. a) Top, of bottorn, 4 1 , floor (including Oasern Brit; arawispaqe or enclosure flo0r) b) Top of the next higher.flogr q) Bottom, of the, lowest horizontal structural member (V Zones only) d) Attached garage (top of ilabl e) Lowest elevation of Machinery or equipment,�servicingthe building (Describe type of eoulpme I nt and location in Comments) f) L9westacijacent (finished) grade next to building (LAM g) Highest,adjatent (finished) grade next to btilldffig (HAG) Loweat adjacent, graoe at lqwost elevation of deals or stb!M' including structural support, information, I tertity that the Informatiorl On this COMM, , understand : brat any false statement may, be. punishable I Fx1 Check here it comments are provided on back of form. O'Check here if. attachments. 279 . 4. 9 feet 0 meters 281, 6, 29 feet Elmeters _280 0 H feet 0 meters 2817 , 1 CK feet 0 meters 2811.. 0 Ck-feet .0 meters feet 0 meters M feet 0 meters ,e , ngtn6er, or architect authorized by law to dertlfY,eleV9J aserits my best efforts tolnterPYLt thO-Oata avallatilp- or Imprisonment under 18 U.S. Code, Section 1001. were latitude and longitude In Section A provided by, 9 licensed land surveyor? [KYes 0,No F15MA Farm 08&0-33 (Revised 7112) Sea reverse aide for toritindation. Replaces ail previous, aditions. and k.u!T11Fy4ktL§ Water Heater located inside of aarne. a) Existino struoturo,is pre-Arrn.'b) Existirm strudture is exempt from having to upd4te to Date 05/20/2946, 990 -TION E'- WILDING ELEVATION INFORMATION (SURM NOT REQUIRED) FOR ZONE AO,AND ZONE A (WtT!L0lUT-BFE,% For Zones Ali and A:(Wlthbut Mt),complete Items EI --E5. if. the Certificate is intended.to, support 0 LOMA or LOMB -F request, complete Sections A, B,and C. For Items, E2154, use natural grade, If available. Check the measurement used. In Puerto Rico only, enter meters. El. Pi#imide ; elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAO). a) Top of bottom floor (Iripludingbasement, crawlsP ace,,or.enc1qsUre)Js ofeet E]meters [] above or 0 below the HAG. b) Top ofbottomfluor (Including basement, craWispacei lir enclosure) .Is Ofeet Ornaters O.aboveor 0 below the LAG. E2. For Bull d I ing Diagrams 6-9 with "permanent flood openingsprovided in Section A Items 8 and/or 0, (see pages 8-9 of Instructions), the next "higher floor (elevation C2,bin the diagrams) of the building is Ofedt '0 meters 0 above or El below the, HAG. E3. Attached g0rage-(top of slab) is ofeet r1meters, Qabove -or 0 below the HAG. E4.'rop of, platform of "machinery and/or e0loment servicing the building is nfeet Ometers 0above or 0 below the, HAG. IE5,Zona AO only., if no flood, depth -number is available, Is the top of the bottom ficur elevated in accordance with the community's floodplain management ordinance? [] Yes, [] No [I Unknown. The local; official must certify this information in section d. The property owner or owner's authorized representative Who completes,sections A, 8, and E.fur Zone A (Without a FEMA-lasued or community -issued BFE) or Zone AD must sign here. The statements In Sections A, B, and E are correct to the best of my "knowledge: Property. 0wri'et or.0wrier's -Authorized, Representative's Name. Address city state ZIP Code ..................... . .... ❑ Check here if attachments. SE' TION - COMMUNITY INFORMATION'(o,P"nONiM) The local o,!Wclal who is authorized bylaw orardinanceto administer the community's floodplain management ordinance can complete Sections A, 8, ddor E), and G Of this Elevation: Ce r.dficata. Compt ote,the applicable, itern(s) and sign below. Check thameasurement used in Items GS -G141 in Puerto Rico only; enter meters. Gi. ®'the info.rmatibn in Secti'dil C Was taken from other documentation that has been.signed and sealed by a licensed surveyoff, engtribet, or architect who Is authorized by law to certify elevation Information, (indicate the source and date of the elevation data in the CDMmentsarpabelow.) G2. 't3 A community offlcl8l completed I Section E for a building located in Zone A (without a FEMXissued or communityJsspqd OFF.) or Zone At? G3. C The following information (items G4 -GIC) is provided for community floodplain management purposes. G4: Permi€ Number G5. Date Permit Issued G6. Date Certificate Of CoMplianap/oapupancy Issued 67. This permit has been issued for: New Construction 0 Substantial Improvement 08, Elevation of:as-bulit lowest floor (Including basement) of the building I Elfeet Ometers Datum G9. BFEor (in zone AO) depth of flooding at the building site.*, 0 feet 13 meters Datum GICF.Community'i deslgn food: elevation:. ©feet ©meters Dotum Local OfficiaPs Name Title Com;�6hl �,Ntme Telephone, Signature Data comments n Check here if attachments. FtMA Form 086-0-33 (Revised 7112) Replaces all previous editions.