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BUILDING PERMIT APPLICATION
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Job Address: I ' ( (�- ICA.,:L�
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Date: C�
Lot: Block:
Subdivision: \1
_ Phase or Section Number:
Owner
,) Address: 'r
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Contractor: tr
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Address:
Description of Work to be Done -
Class�f Work: New
❑Addition ❑Alteration ❑Repair
El Dem
Area of Building in Square Feet
First Floor_;_,
Second Floor
NOTICE
Garage
Other
This permit becomes null and void if work or construction authorized is not commenced
within 180 days, or construction on work is suspended or abandoned for a period of 180 days
at any time after work is commenced.
I hereby certify that I have read and examined this application and know the same to be true
and correct. All provisions of laws and ordinances governing this type of work will be
complied with whether specified herein or not. The granting of a permit does not presume to
give authority to violate or cancel the provisions of any other federal, state or local law
reg u sting construction if $be pe ormance of cTnsction.
o I I cff,l,
Signature of Contractor
t for
FPMC - 1 (4/94)
ilutho'dzed Agent —rtn ' ame
Plumbing Contractor Mechanical Contractor
Value of Work I , i (T /7
to be Performed l I -D{ ) -
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BUILDING INSPECTION - WHITE, APPRAISAL - YELLOW, CUSTOMER - PINK
O.M.B. NO. 3067-0077
ELEVATION CERTIFICATE Expires May 31, 1996
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to
provide elevation information necessary to ensure compliance with applicable community floodplain management ordinances, to
determine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Revision (LOMA or LOMB).
Instructions for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION
FOR INSURANCE COMPANY USE
BUILDING OWNER'S NAME POLICY NUMBER
_1- I t25-1 �`fLXA---
STREET ADDRESS (Including Apt., Unit Suite and/or Bldg. Number) OR P.O. ROUTE AND BOX NUMBER COMPANY MAIC NUMBER
Grlaroma--moo► &t+'[Da,,1_u-_t.-- -- - -- -
OTHER DESCRIPTION (Lot and Block Numbers, etc. I-
i-ms_�_o��a-�-
CITY
STATE ZIP CODE
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provide the following from the proper FIRM (See Instructions):
1. COMMUNITY NUMBER
2. PANEL NUMBER
3. SUFFIX
4. DATE OF FIRM INDEX 5. FIRM ZONE
6. BASE FLOOD ELEVATION
(in AO Zones, use depth)
4 8bs ? o
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p�e►1 �� A
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7. Indicate the elevation datum system used on the FIRM for Base Flood Elevations (BFE);,I NGVD '29 i_ 1 Other (describe on back)
8. For Zones A or V, where no BFE is provided on the FIRM, and the community has established a BFE for this building site, indicate
the community's BFE: LLL_LLJ .❑ feet NGVD (or other FIRM datum -see Section B, Item 7),
SECTION C BUILDING ELEVATION INFORMATION
1. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best
describes the subject building's reference level —1- .
2(a). FIRM Zone Al -A30, AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an elevation
of ❑._1qqla feet NGVD (or other FIRM datum -see Section B, Item 7).
(b). FIRM Zones V1 -V30, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level from
the selected diagram, is at an elevation of L-L-LLI-11-; feet NGVD (or other FIRM datum -see Section B, Item 7).
(c). FIRM Zone A (without BFE). The floor used as the reference level from the selected diagram is LL_j . Ll feet above Ll or
below ❑ (check one) the highest grade adjacent to the building.
(d). FIRM Zone AO. The floor used as the reference level from the selected diagram is LLI . L feet above Lj or below ❑ (check
one) the highest grade adjacent to the building. If no flood depth number is available, is the building's lowest floor (reference
level) elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No -1 Unknown
3. Indicate the elevation datum system used in determining the above reference level elevations: ❑ NGVD '29 J Other (describe
under Comments on Page 2). (NOTE: if the elevation datum used in measuring the elevations is different than that used on
the FIRM (see Section B, Item 7], then convert the elevations to the datum system used on the FIRM and show the conversion
equation under Comments on Page 2.)
4. Elevation reference mark used appears on FIRM Yes F1 No (See Instructions on Page 4)
5. The reference level elevation is based on actual construction ❑construction drawings
(NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which
case this certificate will only be valid for the building during the course of construction. A post -construction Elevation Certificate
will be required once construction is complete.)
6. The elevation of the lowest grade immediately adjacent to the building is: Lj--f Z1�P_j .� 1J feet NGVD (or other FIRM datum -see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
1. If the community official responsible for verifying building elevations specifies that the reference level indicated in Section C, Item 1
is not the "lowest floor" as defined in the community's floodplain management ordinance, the elevation of the building's "lowest
floor" as defined by the ordinance is: LLLI L I. Ll feet NGVD (or other FIRM datum -see Section B, Item 7).
2. Date of the start of construction or substantial improvement _.
FEMA Form 81-31, MAY 93 REPLACES ALL PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION
SECTION E CERTIFICATION
This certification is to be signed by a land surveyor, engineer, or architect who is authorized by state or local law to certify elevation
i information when the elevation information for Zones Al—A30, AE, AI -1, A (with BFE),V1—V30,VE, and V (with BFE) is required.
Community officials who are authorized by local law or ordinance to provide floodplain management information, may also sign the
/ certification. In the case of Zones AO and A (without a FEMA or community issued BFE), a building official, a property owner, or an
owner's representative may also sign the certification.
Reference level diagrams 6, 7 and 8 - Distinguishing Features—If the certifier is unable to certify to breakaway/non-breakaway wall,
enclosure size, location of servicing equipment, area use, wall openings, or unfinished area Feature(s), then list the Feature(s) not
included in the certification under Comments below. The diagram number, Section C, Item 1, must still be entered.
1 certify that the information in Sections B and C on this certificate represents my best efforts to interpret the data available.
understand that any false statement may be punishable by fine it under 18 U.S. Code, Section 1001.
CERTIFIER'S NAME
TITLE
, 9 4.
ADDS SS w -10,
(or Affix Seal)
— / STATE ZIP
f$
DAL E i _ _P1 ]ONE
J_
Copies should be made of this Certificate for: 1) community oflicial, 2) insurance agent/company, and 3) building owner.
COMMENTS:
ON WIT -N ON PILES,
SLAB BASEMEN r PIERS, on COLUMNS
A V A A V
ZONES ZONES ZONES ZONES ZONES
.� REFERENCE
LEVEL
REFERENCE
REFERENCE BASE
LEVEL
LEVEL FLOOD
ELEVAIION
BASE ADJACENT tr nEFERENCE
FLOOD• LEVEL
BASE
FLOOD
ELEVATION
GRADE
ELEVATION REFERENCE ADJACENT
LEVEL GRAUE
'..5�.?.: ;.:il....'.: i.f:j:Sf(•:, 'r`;!
ADJACENT..'..'.
GRADE
The diagrams above illustrate the points at which the elevations should be measured in A Zones and V Zones.
Elevations for all A Zones should be measured at the top of the reference level floor.
Elevations for all V Zones should be measured at the bottom of the lowest horizontal structural mernber.
Page 2
SUFIVEY PLAT OF .
TO ALL PARTIES INTERESTED IN PREMISIF.1 SURVEYLD:
A Refisrered l`NfrssooAL3rw1 Surc_eyor. do hereby certjlLthat a careful survey was made of the ground Chic date untler me su otsinn nl the /ollntti
and there are encroachments uprm the adjoining property or the adioining improvements upon the described progeny known It
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STATE OF TEXAS
COUNTY OF TARRANT
" to the Lienholders and/or the Owners of the Premises surveyed and to
I lie undersigned does hereby certify that this survey was this day made
on the ground of the property legally described hereon and is correct, and that
there are no discrepancies, conflicts, shortages in area, boundary line conflicts.
encroachments, overlapping of improvements, visible lines or roads in place.
except ac shown hrrron on,' #bar eairl pr,%r" Les ;tc—;s to and from a
dedicated roadway except as shown hereon."
Dated:
BASIS fOR nFARINO:
Ordcr No..--�_--
NOT FOR CONSTRUCTION
ScALE 1" - 20'
00'
\V, 10110 9 S
PLOOD NOTE: 1 hereby certify that the propetty detcribed herein
—__ within a special flood hazard lifts 99 identified b% the
Federal Insurance Administration. Department of Nolising and Urban
Development, the flood hazard area being identified At
of the Federal Insurance Adnihil Rotiotl Fhwd Ita7ard
Boundary Map effective on ---
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k AP SURVEYING CO.
David Pollard RPS N 1518
1903 Central Drive, Suite 309
Bedford. TX 76021 Metro (817) 2674249
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14 Builder
STREET CUT
F.E.M.A. LETTER REQUIRED.
PLANS ARE REVIEWED FOP,
MINIMUM jr, f. a
APPROVAL OF SINGLE
FAMILY RESIDENCE ONLY. FORM BOARD
OTHER DEPICTIONS OR SURVEY READ
CALL -OUTS ON PLOT PLAN
HAVEAND ARE BEEN REVI9WED
APPROVED,,".? .
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