HomeMy WebLinkAboutFLD2023-00043 Elevation Cert - BLD Application - 6/5/2023 MASON COUNTY Mason County Permit Center Use:
COMMUNITY SERVICES FLD 202 3 - 0064J
Building,Planning,Environmental Health,Community Health
615 W.Alder Street—Bldg.8,Shelton,WA 98584 Date Rcvd tp-5-20 2 J
Phone:(360)427-9670 Ext.352 ♦ Fax:(360)427-7798
Fee: $300.00
No fee if w/other permits
FDPO Development Permit Application
Applicant:Cameron Jurgensen Contractor:N/A - Owner Contractor
Mailing Address: PO Box 791 Mailing Address: ,
City, State, Zip Allyn, WA 98524 City, State, Zip„ ,
Phone: ( )253-380-9250 Phone: ( ) ,
Email: Email:
Parcel Number: 122171400050 Property Address:
790 East North Bay Road, Allyn, W
I understand I am making application for a permit to develop in a designated flood hazard area. The
undersigned agrees that all such work shall be done in accordance with the requirements of the County Flood
Damage Prevention Ordinance, building codes and all other applicable Local, State and Federal regulations.
This application does not create liability the part of the County or any officer or employee thereof for any
flood damage that results f�o reliance n his application or any administrative decision made lawfully
thereunder.
i
Applicants Signature: Date:
Official Use:
A. Description of Work (complete for all work):
1. Proposed Development Description:
EI New building/Addition ❑ Manufactured home ❑ Fill/grade ❑ Other:
❑ Commercial (see section D)
El Remodel/repair to existing building (see section C)
2. The parcel has been identified in the following Flood Hazard Area:
❑ A )(AE ❑ AO ❑ VE 1�>F,E t 5*"
3. Are any other Federal, State or local permits required? Must attach copies of permits.
❑ Yes 17 No If yes, list type:
4. Is the proposed development in an identified floodway?
❑Yes El No
5. If yes to #4, a No Rise Certification must be attached.
0 Yes EI No
B. Complete for New Structures and Building Sites:
1. A FEMA Elevation Certificate is required, must be completed by a Washington State licensed Surveyor.
Must attach a copy of certificate.
2. Base Flood Elevation at the building site: 13 feet NAVD 88
3. Required lowest floor elevation (including basement floor): 14 feet NAVD88
4. In flood hazard areas without a base flood elevation (BFE), what is the highest adjacent
Grade? (HAG)
Structure must be a minimum of two (2) feet above the HAG.
The required finish floor height is
C. Complete for Alterations, Additions, or Improvements to Existing Structures:
******(See attached Substantial Improvement & Substantial Repair)*******
1. What is the estimated market value of the existing structure? $280,000
2. What is the cost/valuation of the proposed construction? $100,000 Percentage35.7%
3. If the cost or valuation of the proposed construction equals or exceeds 50 percent of the market value
of the structure, then the substantial improvement/repair provisions shall apply.
Is the proposed work a substantial repair/improvement ❑ Yes El No
D. Complete for Non-Residential Floodproofed Construction:
1. Type of floodproofing method:
2. The required floodproofing elevation is: feet NAVD88
3. F000dproofing certification by a registered engineer is attached:
❑ Yes ❑ No
E. Complete for Subdivisions and Planned Unit Developments:
1. Will the subdivision or other development contain 50 lots or 5 acres?
❑ Yes ❑ No
2. If yes, does the plat or proposal clearly identify base flood elevations?
❑ Yes ❑ No
3. Are the 100 Year Floodplain and Floodway delineated on the site plan?
❑ Yes ❑ No
Administrative
-10-25
1. APPROVED- �jjVNIED: statement attached
2. Elevation Certificate attached. Yes ❑ No
3. As-built lowest floor elevation: feet NAVD88
Comments/Conditions:
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Mason County Flood Damage Prevention Ordinance #41-17 & International Building Codes
a'L&A-�)Oy-1 .
U.S. DEPARTMENT OF HOMELAND SECURITY OMB No. 1660-0008
Federal Emergency Management Agency Expiration Date: November 30, 2022
National Flood Insurance Program
ELEVATION CERTIFICATE
Important: Follow the instructions on pages 1-9.
Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insurance agent/company, and (3)building owner.
SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE
Al. Building Owner's Name Policy Number:
Cameron Jurgensen
A2. Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Company NAIC Number:
Box No.
790 E North Bay Road
City State ZIP Code
Allyn Washington 98524
A3. Property Description(Lot and Block Numbers,Tax Parcel Number, Legal Description, etc.)
Tax Parcel No. 12217-14-00050
A4. Building Use(e.g., Residential, Non-Residential,Addition,Accessory, etc.) Residential
A5. Latitude/Longitude: Lat.47.397041° Long.-122.824315* Horizontal Datum: ❑ NAD 1927 x❑ NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
A7. Building Diagram Number 8
A8. For a building with a crawlspace or enclosure(s):
a) Square footage of crawlspace or enclosure(s) 528.00 sq ft
b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade 2
c) Total net area of flood openings in A8.b 1656.00 sq in
d) Engineered flood openings? ❑Yes 0 No
A9. For a building with an attached garage:
a) Square footage of attached garage N/A sq ft
b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade N/A
c) Total net area of flood openings in A9.b N/A sq in
d) Engineered flood openings? ❑ Yes x❑ No
SECTION B—FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP Community Name&Community Number B2. County Name B3. State
Mason County 530115 Mason County Washington
B4. Map/Panel B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9. Base Flood Elevation(s)
Number Date Effective/ Zone(s) (Zone AO, use Base Flood Depth)
Revised Date
53045CO340 E 06-20-2019 06-20-2019 AE, X 13.0
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9:
❑ FIS Profile ❑x FIRM ❑ Community Determined ❑ Other/Source:
B11. Indicate elevation datum used for BFE in Item 139: ❑ NGVD 1929 x❑ NAVD 1988 ❑ Other/Source:
B12. Is the building located in a Coastal Barrier Resources System (CBRS)area or Otherwise Protected Area (OPA)? ❑ Yes ❑X No
Designation Date: ❑ CBRS ❑ OPA
FEMA Form 086-0-33 (12/19) Replaces all previous editions. Form Page 1 of 6
OMB No. 1660-0008
ELEVATION CERTIFICATE Expiration Date: November 30, 2022
IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No. Policy Number:
790 E North Bay Road
City State ZIP Code Company NAIC Number
Allyn Washington 98524
SECTION C-BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction` ❑x Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations-Zones Al-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO.
Complete Items C2.a-h below according to the building diagram specified in Item A7. In Puerto Rico only,enter meters.
Benchmark Utilized: SmartNetNA Vertical Datum: NAVD 1988
Indicate elevation datum used for the elevations in items a)through h)below.
❑ NGVD 1929 Fx-] NAVD 1988 ❑ Other/Source:
Datum used for building elevations must be the same as that used for the BFE.
Check the measurement used.
a) Top of bottom floor(including basement,crawlspace,or enclosure floor) 12.3 feet ❑ meters
b) Top of the next higher floor 13.6 feet ❑ meters
c) Bottom of the lowest horizontal structural member(V Zones only) N/A X feet ❑ meters
d) Attached garage(top of slab) N/A 0 feet ❑ meters
e) Lowest elevation of machinery or equipment servicing the building 13.6 ❑x feet ❑ meters
(Describe type of equipment and location in Comments)
f) Lowest adjacent(finished)grade next to building (LAG) 12.4 ❑x feet ❑ meters
g) Highest adjacent(finished)grade next to building(HAG) 12.8 ❑x feet ❑ meters
h) Lowest adjacent grade at lowest elevation of deck or stairs, including
structural support 12.5 x❑ feet ❑ meters
SECTION D-SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor,engineer, or architect authorized by law to certify elevation information.
/certify that the information on this Certificate represents my best efforts to interpret the data available. /understand that any false
statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
Were latitude and longitude in Section A provided by a licensed land surveyor? 0 Yes ❑No ❑Check here if attachments.
Certifier's Name License Number
Daniel B. Johnson 28408 *� g JO
Title 6
Managing Director
Company Name
Aspen Land Surveying LLC o
Address 28408
15510 92nd Street NW, Suite A `nscrsTE?�° a
City State ZIP Code
Gig Harbor Washington 98329
Signature Date Telephone Ext.
02-24-2023 (253)303-0270
Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insurance agent/company,and (3)building owner.
Comments(including type of equipment and location, per C2(e), if applicable)
A8(b): See photos
C2(e): Water Heater
FEMA Form 086-0-33 (12/19) Replaces all previous editions. Form Page 2 of 6
OMB No. 1660-0008
ELEVATION CERTIFICATE Expiration Date: November 30, 2022
IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No, Policy Number:
790 E North Bay Road
,City State ZIP Code Company NAIC Number
Allyn Washington 98524
SECTION E—BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED)
FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE), complete Items E1—E5. If the Certificate is intended to support a LOMA or LOMR-F request,
complete Sections A, B,and C. For Items E1—E4, use natural grade, if available. Check the measurement used. In Puerto Rico only,
enter meters.
E1. Provide 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 (LAG).
a) Top of bottom floor(including basement,
crawlspace, or enclosure)is ❑x feet ❑meters ❑above or ❑ below the HAG.
b) Top of bottom floor(including basement,
crawlspace,or enclosure)is ❑x feet ❑meters ❑above or ❑ below the LAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9 (see pages 1-2 of Instructions),
the next higher floor(elevation C2.b in
the diagrams)of the building is ❑x feet ❑meters ❑above or ❑below the HAG.
E3. Attached garage(top of slab)is ❑x feet ❑ meters ❑above or ❑below the HAG.
E4. Top of platform of machinery and/or equipment
servicing the building is X feet ❑ meters ❑above or ❑below the HAG.
E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's
floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G.
SECTION F—PROPERTY OWNER(OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A(without a FEMA-issued or
community-issued BFE)or Zone AO must sign here.The statements in Sections A, B, and E are correct to the best of my knowledge.
Property Owner or Owner's Authorized Representative's Name
Address City State ZIP Code
Signature Date Telephone
Comments
❑ Check here if attachments.
FEMA Form 086-0-33(12/19) Replaces all previous editions. Form Page 3 of 6
OMB No. 1660-0008
ELEVATION CERTIFICATE Expiration Date: November 30, 2022
IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number:
790 E North Bay Road
City State ZIP Code Company NAIC Number
Allyn Washington 98524
SECTION G—COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete
Sections A, B, C(or E), and G of this Elevation Certificate. Complete the applicable item(s)and sign below. Check the measurement
used in Items G8—G10. In Puerto Rico only,enter meters.
G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,
engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation
data in the Comments area below.)
G2 ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)
or Zone AO.
G3. ❑ The following information(Items G4—G10)is provided for community floodplain management purposes.
G4. Permit Number G5. Date Permit Issued G6. Date Certificate of
Compliance/Occupancy Issued
G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement
G8. Elevation of as-built lowest floor(including basement)
of the building: ❑ feet ❑ meters Datum
G9. BFE or(in Zone AO)depth of flooding at the building site: ❑ feet ❑ meters Datum
G10. Community's design flood elevation: ❑ feet ❑ meters Datum
Local Official's Name Title
Community Name Telephone
Signature Date
Comments(including type of equipment and location, per C2(e), if applicable)
❑ Check here if attachments.
FEMA Form 086-0-33 (12/19) Replaces all previous editions. Form Page 4 of 6
• I BUILDING PHOTOGRAPHS OMB No. 1660-0008
ELEVATION CERTIFICATE See Instructions for Item A6. Expiration Date: November 30, 2022
IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number:
790 E North Bay Road
City State ZIP Code Company NAIC Number
Allyn Washington 98524
If using the Elevation Certificate to obtain NFIP flood insurance, affix at least 2 building photographs below according to the
instructions for Item A6. Identify all photographs with date taken; "Front View"and'Rear View"; and, if required, 'Right Side View"and
"Left Side View." When applicable, photographs must show the foundation with representative examples of the flood openings or
vents, as indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page.
,•,
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,
Photo One
Photo One Caption SOUTH&WEST SIDES 02-08-2023 Clear Photo One
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Photo Two
Photo Two Caption NORTH &WEST SIDES 02-08-2023 Clear Photo Two
FEMA Form 086-0-33 (12/19) Replaces all previous editions. Form Page 5 of 6
BUILDING PHOTOGRAPHS OMB No. 1660-0008
ELEVATION CERTIFICATE Continuation Page Expiration Date: November 30,2022
IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number:
790 E North Bay Road
City State ZIP Code Company NAIC Number
Allyn Washington 98524
If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs
with: date taken; "Front View" and "Rear View"; and, if required, 'Right Side View" and "Left Side View." When applicable,
photographs must show the foundation with representative examples of the flood openings or vents, as indicated in Section A8.
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Photo Three
Photo Three Caption NORTH&EAST SIDES 02-08-2023III Clear Photo Three
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Photo Four
Photo Four Caption SOUTH &EAST SIDES 02-08-2023 Clear Photo Four
FEMA Form 086-0-33 (12/19) Replaces all previous editions. Form Page 6 of 6
TOPOGRAPHIC SURVEY
FOR CAMERON JURGENSEN IN
MASON COUNTY, WASHINGTON
LEGAL DESCRIPTION
A TRACT OF LAND IN GOVERNMENT LOT 2,SECTION 17, TOWNSHIP 22 NORTH,RANGE 1 WEST, W.Y.,PARTICULARLY DESCRIBED AS FOLLOWS:
COMMENCING AT THE SOUTHEASTERLY CORNER OF SAID GOVERNMENT LOT 2;THENCE NORTHERLY ALONG THE EASTERLY LINE OF SAID GOVERNMENT LOT 2,
150 FEET;THENCE WESTERLY,PARALLEL WITH THE SOUTH LINE OF SAID GOVERNMENT LOT 2, TO THE EASTERLY RIGHT-OF-WAY LINE OF STATE ROUTE NO.
302,SAID POINT BEING THE NORTHWESTERLY CORNER OF A TRACT OF LAND CONVEYED TO WALTER W.HOLUS IN WARRANTY DEED RECORDED UNDER
AUDITOR'S FILE NO.103050,AND THE POW OF BEGINNING OF THE TRACT OF LAND HEREBY DESCRIBED;THENCE NORTHERLY ALONG SAID EASTERLY RIGHT
OF-WAY LINE 50 FEET,TO THE NORTHWEST CORNER OF A TRACT OF LAND CONVEYED TO MID L.ELR IN WARRANTY DRED RECORDED TINDER AUDITOR'S FILE
NO.169961;THENCE EAST,300 FEET,MORE OR LESS TO THE EASTERLY LINE OF SAID GOVERNMENT LOT 2;THENCE SOUTHERLY,ALONG SAID EASTERLY
LINE, TO THE NORTHEAST CORNER OF SAM HOLLIS TRACT;THENCE WEST,ALONG THE NORTH LINE OF SAID HOLIS TRACT,300 FEET,MORE OR LESS, TO
THE POINT OF BEGINNING.
PER STATUTORY WARRANTY DEED RECORDED UNDER AFN 2074755.
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VICINITY MAP 4�so p icyE9P at The Landing in Key Center LLC SEC. 77, T 22 N,R I W, W.M.
ANAL Lom P.O. Box 124, Vaughn, WA 98394-0124
SCALE.1"=1/4 MILE 15510 - 92nd Street NW, Gig Harbor, WA 98329 MASON COUNTY, WASHAVGTON
SEC. 17, T.22 N. R. !E., W.M. DANIEL B. JOHNSON (253) 303-0270 FAX (253) 303-0273
CE'RTIMATE N0. '.D.
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MASON COUNTY, WASHINGTON
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SITE:: LEGAL DESCRIPTION
5 - -�- - 17 L- -
17 A TRACT OF LAND IN GOVERNMENT LOT 2,SECTION 17,TOWNSHIP 22 NORTH,RANGE 1 HEST,W.M.,PAR77CULARLY DESCRIBED AS FOLLOWS;
dry COMMENCING AT THE SOUTHEASTERLY CORNER OF SAD)GOYLVaUN7 LOT 2;THENCE NORTHERLY ALONG THE EASTERLY LINE OF SAID GOVERNMENT LOT Z
150 FEET;77 ENCE WESTERLY,PARALLEL WITH TIM SOU771 LINE OF SAID GOVERNMENT LOT 2, TO 771E EASTERLY RIGHT-OF-WAY LINE OF STATE ROUTE NO.
I� Q9 i 302,SAM POINT BEING THIN NORTHWESTERLY CORNER OF A TRACT OF LAND CONVEYED TO WALTER W.HOLLIS IN WARRANTY DEED RECORDED UNDER
IG i AUDTTORSS FILE NO.103050,AND THE POINT OF BEGINNING OF THE TRACT OF LAND REMY DESCRIBED;TMWCE NORTNERLY ALONG SAND EASTERLY RIGHT
y W " OF-WAY LINE 50 FEET,TO THE NORTHWEST CORNET!OF A TRACT OF LAND CONVEYED TO 1DL0 LELR IN WARRANTY DEED RECORDED UNDER AUDITORS FIE
NO.169961;THENCE EAST,300 FEET,MORE OR LESS TO THE EASTERLY LINE OF SAID GOVERNMENT LOT 2;77MCK SOUTHERLY,ALONG SAID FASTERLY
VICINITY MAP LINE, TO THN NORTHEAST CORNER OF SAID HOLLIS TRACT, THENCE WEST ALONG THE NORTH LINE OF SAID HOLLIS TRACT,300 FEET,MORE OR Less, TO
THE POINT OF BEGINNING.
SCALE.I'=114 MUE
SEC. 17, T.22 N., R. 1 A, W.M.
PER STATUTORY VARW17Y DEED RECORDED UNDER AFN 2074755.
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LEGEND
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MADE BY ME OR UNDER MY DIREC770M IN 2194 D
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SURVEY REGARDING ACT AT THE REQUEST OFLand Surveying SE I/4 OF 7FE N£% IN WLUME rJZ OF SURVEYS PAGE 2U(0
AT THE REOU£ST OF 'BUT La SfFYBEflIl9 LLC, RECORDING FEE$207-50
OIE:c CAMERON /URGENSEN saTo`'F"` e`g' aL INeLandkq in Key Center LLC SEC 17, T 22 N,R 1 W, W.M.
j `^ A'AL LAND P.O. Box 124. Y—ghn, NA 98394-0124
N"'— IN FEBRUARY,,202J 1•1 DANEEL H. JOHNSON 15510 - 92nd Street NW, Gig Harbor, WA 98329 MASON COLINTY WAN*VC'TON
CRUTWICAiT ND.MOO (253) 303-0270 FAX (253) 303-0273 COl(NSqtqR