BPP-17-1904Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
nspection Number: INSP-309070 Permit Number: BPP-7-17-1904
Inspection Date: July 25, 2018
Inspector: Kendall, Travis
Owner: KUSKUNOV, GABRIEL MARTIN
Job Address: 1050 NE 107 Street
Miami Shores, FL 33161-7374
Project: <NONE>
Contractor: SUNSET POOL AND SPA
Permit Type: Pools/Whirlpools/Hot Tubs
Inspection Type: Survey Final
Work Classification: New
Phone Number
Parcel Number 1122320280520
Phone: (305)804-1068
Building Department Comments
BUILD A NEW POOL
Infractio Passed Comments
INSPECTOR COMMENTS False
Passed \i,
Inspector Comments
Failed
Correction
Needed
Re -Inspection
Fee
No Additional Inspections can be scheduled
re -inspection fee is paid.
until
For Inspections please call: (305)762-4949
July 25, 2018
Page 1 of 1
1
1150 E. ATLANTIC BLVD.
POMPANO BEACH
FLORIDA 33060
illirkCCURATE LAND SURVEYORS, INC.
L.B. #3635 I SHEET 1 OF 2
TEL. (954) 782-1441
FAX. (954) 782-1442
TYPE OF SURVEY: BOUNDARY
TOPO,15-2215,17-2725
JOB NUMBER: SU-14-1278
LEGAL DESCRIPTION:
LOT 1, BLOCK 4, OF MIAMI SHORES ESTATES, ACCORDING TO THE PLAT THEREOF, AS RECORDED IN PLAT
BOOK 47, PAGE 58, OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, FLORIDA.
ADDRESS: 1050 NE 107TH STREET MIAMI SHORES, FL 33161
FLOOD ZONE:
BASE FLOOD ELEVATION:
CONTROL PANEL NUMBER:
EFFECTIVE: 9/11/2009
X
N/A
120652-0306-L
REVISED: 9/11/2009
LOWEST FLOOR ELEVATION: "SEE SKETCH"
GARAGE FLOOR ELEVATION: N/A
LOWEST ADJACENT GRADE : "SEE SKETCH"
HIGHEST ADJACENT GRADE : "SEE SKETCH"
REFERENCE BENCH MARK: DCBM#B-26-RA ELEV:17.23'NGVD
CERTIFY TO:
1 GABRIEL MARTIN KUSKUNOV
2.
3.
4.
5.
NOTES:
1. THIS SURVEY CONSISTS OF A MAP AND A TEXT REPORT. ONE IS NOT VAUD WITHOUT THE OTHER.
2. OWNERSHIP OF FENCE AND WALLS IF ANY, NOT DETERMINED.
3. THIS SURVEY IS MADE FOR THE EXCLUSIVE USE OF THE CERTIFIED HEREON. TO BE VALID ONE YEAR
A
A
CB
R
RAN
P.C.
P.T.
WM
OH
N
S
W
8.M.
FH
o/s
SEC.
TWP.
RGE.
• CENTRAL ANGLE
• ARC LENGTH
= CHORD BEARING
• RADIUS
= RIGHT OF WAY
• POINT OF CURVATURE
= POINT OF TANGENCY
• WATER METER
= OVERHANG
• NORTH
= SOUTH
• EAST
= WEST
= BENCHMARK
= FIRE HYDRANT
• OFFSET
= SECTION
= TOWNSHIP
= RANGE
4.
00 LEGEND OF ABBREVIATIONS:
OR+• ELEVATIONS BASED ON NGVD 1929
SQ. FT. = SQUARE FEET
P.C.P. = PERMANENT CONTROL POINT
P.B.C.R. • PALM BEACH COUNTY RECORDS
p • PLAT
N&D
P.O.C.
P.O.B.
A/C
FND.
CHATT.
F.P.L
ELEV.
MH
ESMT.
ELEC.
• NAIL & DISC
• POINT OF COMMENCEMENT
• POINT OF BEGINNING
= " AIR CONDITIONER
• i FOUND
= CHATTAHOOCHEE
• FLORID&POWER &
= ELEVATIONS
• MANHOLE
= EASEMENT
• ELECTRIC
MAINT.
B.C.R.
O.C.R.
P.B.
O.R.B.
F.F.
ENCH.
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FROM THE DATE OF SURVEY AS SHOWN HEREON.
MIAMI-DADE COUNTY NGVD1929
• MAINTENANCE
= BROWARD COUNTY RECORDS
= DADE COUNTY RECORDS
= PLAT BOOK
• OFFICIAL RECORDS BOOK
= FINISHED FLOOR
= ENCROACH
-x-x-x-x-
- •
11 11 II it -
hh h h, h h -
CHAIN LINK FENCE
WOOD FENCE
METAL FENCE
PVC FENCE
CONCRETE FENCE
CONCRETE WALL
WIRE FENCE
D.B. •
CLF =
WF
BLVD. •
AD =
I.M.
I.R.
GAR. •
C/L =
(M)
LP
U.E. •
D.E.
AE.
P.R.M. •
N.G.V.D.
DEED BOOK
CHAIN LINK FENCE
WOOD FENCE
BOULEVARD
ASSUMED DATUM
IRON PIPE
IRON ROD
GARAGE
CENTERLINE
MEASURED
LIGHT POLE
UTILITY EASEMENT
DRAINAGE EASEMENT
ANCHOR EASEMENT
PERMANENT REFERENCE MONUMENT
NORTH GEODETIC VERTICAL DATUM
E A
NOT VAUD WITHOUT
THE SIGNATURE AND
THE ORIGINAL RAISED
SEAL OF A FLORIDA
UCENSED SURVEYOR
AND MAPPER.
1150 E. ATLANTIC BLVD.
' POMPANO BEACH
FLORIDA 33060
Cl
RADIUS=25.00'
DELTA=75'51'26"
ARC=32.99'
TAN=19.39'
h° DENOTES ELEVATIONS BASED ON N.G.V.D.
20 0 10 20-
GRAPHIC SCALE
1 "=20'
OVERH;
UTILITY
WIRES
RESIDENCE
#1050
UNDER
CONSTRUCTION'.'.'.
1
O +4.
TEMPORARY 6'
CHAINLINK
629 FENCE
*�(.� v`V FOUND
IRON ROD
NO I.D.
co
N
M
47.44
20' ASPHALT PAVEMENT,;•
14TH P LA
co
O
41
442
NAIL ... '*FOUND 5/8"
SC ON ROD
''v-'o,-" NO ID
o/s 1.23'E
0.62'S
FENCE
5.4'W
0.5'S
4' CY41y••
LINK FEN tE
000000
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•
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0
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FENCE
0.4'S
FOUND 1/2"
IRON PIPE
NO ID
0
S e�
gib•
N
NOTES:
1. UNLESS OTHERWISE NOTED FIELD MEASUREMENTS ARE IN AGREEMENT WITH RECORD
MEASUREMENTS.
2. BEARINGS SHOWN HEREON ARE BASED ON A BEARING OF N/A.
3. THE LANDS SHOWN HEREON WERE NOT ABSTRACTED FOR OWNERSHIP, RIGHTS —OF —WAY,
EASEMENTS, OR OTHER MATTERS OF RECORDS BY ACCURATE LAND SURVEYORS, INC.
4. OWNERSHIP OF FENCES AND WALLS IF ANY NOT DETERMINED.
5. THIS DRAWING IS THE PROPERTY OF ACCURATE LAND SURVEYORS, INC. AND SHALL NOT
BE USED OR REPRODUCTED IN WHOLE OR IN PART WITHOUT WRITTEN AUTHORIZATION.
6. THIS SURVEY CONSISTS OF A MAP AND TEXT REPORT. ONE IS NOT VALID WITHOUT THE
OTHER.
7. THIS SURVEY IS MADE FOR THE EXCLUSIVE USE OF THE CERTIFIED HEREON, TO BE
VALID ONE YEAR FROM THE DATE OF SURVEY AS SHOWN.
8. THE FLOOD ZONE INFORMATION SHOWN HEREON IS FOR THE DWELLABLE STRUCTURE
ONLY UNLESS OTHERWISE INDICATED.
9. THE LOCATION OF OVERHEAD UTILITY LINES ARE APPROXIMATE IN NATURE DUE TO
THEIR PROXIMITY ABOVE GROUND. SIZE, TYPE & QUANTITY MUST BE VERIFIED PRIOR TO
DESIGN OR CONSTRUCTION.
REVISIONS
DATE
BY
UPDATE SURVEY SU-17-2725
08-17-17
AL/RLT
TREE SURVEY SU-15-3388
09-10-15
AL/RLT
UPDATE/TOPO SU-15-2215
07-02-15
AL/JMS
UPDATE/TOPO SU-14-2450
08-07-14
AL/MLW
CERTIFICATION:
THIS IS TO CERTIFY THAT THIS ABOVE GROUND SKETCH OF
BOUNDARY SURVEY WAS MADE UNDER MY RESPONSIBLE CHARGE AND
IS ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND
BELIEF. 1 FURTHER CERTIFY THAT THIS SKETCH MEETS THE CURRENT
STANDARDS OF PRACTICE, ESTABLISHED BY THE BOARD OF
PROFESSIONAL SURVEYORS AND MAPPERS, CHAPTER 5J-17, FLORIDA
ADMINISTRATIVE CODES, PURSUANT TO SECTION 472.027, FLORIDA
STATUTES.
E A c
NOT VALID WITHOUT
THE SIGNATURE AND
THE ORIGINAL RAISED
SEAL OF A FLORIDA
LICENSED SURVEYOR
APPER.
ROBERT L. THOMPSON (PRESIDENT)
PROFESSIONAL SURVEYOR AND MAPPER No.3869 — STATE OF FLORIDA
DATE OF SURVEY
05/02/14
DRAWN BY
ODI
CHECKED BY
JMS
FIELD BOOK
14-1278
SCALE 1 "= 20'
NAM RSU-14-1278
ti.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
OMB No. 1660-0008
Expiration Date: November 30, 2018
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:
GABRIEL MARTIN KUSKUNOV
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and
Box No.
Company NAIC Number:
1050 NE 107TH STREET
City State ZIP Code
MIAMI SHORES Florida 33161
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
LOT 1, BLOCK 4, OF MIAMI SHORES ESTATES, PB 47, PG 58, CR, FOLIO#11-2232-028-0520
A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.)
RESIDENTIAL • • • • • •
••••.
Horizontal
Datum: •[i•NAD 1927 • NAD 1984 • •
A5. Latitude/Longitude:
Lat. N25°52'26.4" Long. W80°10'33.2"
•...•. .
•
• • • • •' •
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insuranca.• •. .
Building Diagram Number
1A
•A7.
•,•••• ••• •. •:•••'•
• •• •••••
A8. For a building with a crawlspace or enclosure(s): •'• • •• • • •. •
•
.•••••• • • •. • •
a) Square footage of crawlspace or enclosure(s)
N/A sq ft
• • • • •. .
• . .
b) Number of permanent flood openings in the crawlspace or enclosure(s) within 1.0 foot abovedjacent grade
At ....:.
• • •
• .
c) Total net area of flood openings
in A8.b N/A sq in
•
• • •• •. • : • • •..
• . • •
d) .Engineered flood openings?
•• •
❑ Yes X 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
MIAMI SHORES 120652
MIAMI-DADE
Florida
B4. Map/Panel
B5. Suffix
B6. FIRM Index
B7. FIRM Panel
B8. Flood
B9. Base Flood E evation(s)
Number
Date
Effective/
Zone(s)
(Zone AO, use Base Flood Depth)
Revised Date
12053C0306
L
09-11-2009
09-11-2009
X
N/A
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 B9:
1929
❑ NAVD 1988 ❑ Other/Source:
x NGVD
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected
Area (OPA)?
❑ Yes x No
Designation
Date: N/A ❑
CBRS ❑ OPA
FEMA Form 086-0-33 (7/15)
Replaces all previous editions.
Form Page 1 of 6
ELEVATION CERTIFICATE
OMB No. 1660-0008
Expiration Date: November 30, 2018
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.
1050 NE 107TH STREET
Policy Number:
City State ZIP Code
MIAMI SHORES Florida 33161
Company NAIC Number
SECTION C — BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
❑ Finished Constnuctia;n
AR/A1—A30, AR/AH, AR/AO.
Rico only, enter meters.
C1. Building elevations are based on: ❑ Construction Drawings* x Building Under Construction*
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations — Zones A1—A30, AE, AH, A (with BFE), VE, V1—V30, V (with BFE), AR, AR/A, AR/AE,
Complete Items C2.a—h below according to the building diagram specified in Item A7. In Puerto
Benchmark Utilized: DCBM#B-26*RA EL:17.23' Vertical Datum: NGVD
Indicate elevation datum used for the elevations in items a) through h) below.
x NGVD 1929 ❑ NAVD 1988 ❑ Other/Source:
Datum used for building elevations must be the same as that used for the BFE.
a) Top of bottom floor (including basement, crawlspace, or enclosure floor) 9.92
Check the measurement used.
! feet •. � meters•
•
b) Top of the next higher floor N/A. L] feet • • {t] meters . •
•
• c) Bottom of the lowest horizontal structural member (V Zones only) N✓,A.: feet [� meters' • • • •.
d) Attached garage (top of slab) NW
. •
• 1;1 feet; •r eterl' •.. •:
.
•• ••
e) Lowest elevation of machinery or equipment servicing the building • • • • •
(Describe type of equipment and location in Comments) 9,. • rf �9feet •• rj•rs mete• •..
• ......
f) Lowest adjacent (finished) grade next to building (LAG) $.57; •1] feet FI] meters . •
g) Highest adjacent (finished) grade next to building (HAG) 9.04•. ❑ fee( • • •C} meters' •• • •
•h) Lowest adjacent grade at lowest elevation of deck or stairs, including
structural support
• • • • •
N/A ❑ 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
I certify that the information on this Certificate represents my best efforts to interpret the data available.
statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
law to certify elevation information.
I understand that any false
❑ Check here if attachments.
Were latitude and longitude in Section A provided by a licensed land surveyor? x Yes ❑ No
Certifier's Name License Number
ROBERT L. THOMPSON 3869
3G?6.
CJJ
eal
Here
Title •
PROFESSIONAL SURVEYOR & MAPPER
Company Name
ACCURATE LAND SURVEYORS, INC.
Address
1150 E ATLANTIC BOULEVARD
City State ZIP Code
POMPANO BEACH Florida 33060
r;'---/`-7---,/
Signature Date Telephone Ext.
08-17-2017 (954) 782-1441 N/A
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)
JOB NO. 14-1278 17-2725 A5: Lat and Long was obtained using a hand held GPS unit. C2E: A/C PAD
FEMA Form 086-0-33 (7/15)
Replaces all previous editions.
Form Page 2 of 6
ELEVATION CERTIFICATE
OMB No. 1660-0008
Expiration Date: November 30, 2018
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.
1050 NE 107TH STREET .
Policy Number:
City State ZIP Code
MIAMI SHORES Florida 33161
Company NAIC Number
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 El—E5. If the Certificate is intended to support a
complete Sections A, B,and C. For Items El—E4, use natural grade, if available. Check the measurement
enter meters.
El. Provide elevation information for the following and check the appropriate boxes to show whether
the highest adjacent grade (HAG) and the lowest adjacent grade (LAG).
a) Top of bottom floor (including basement,
crawlspace, or enclosure) is ❑ feet ❑ meters
LOMA or LOMR-F request,
used. In Puerto Rico only,
the elevation is above or below
❑ above or ❑ below the HAG.
❑ above or ❑ below the LAG.
9 (see pages 1-2 of trslagructions),
•. • . • • • • • •
b) Top of bottom floor (including basement,
crawlspace, or enclosure) is ❑ feet ❑ meters
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or
the next higher floor (elevation C2.b in
the diagrams) of the building is ❑ feet ❑ meters
•[rove or.i betw the HA6
.
•rf above or ❑below the, HAG.•
• I shove or �I;e=low the utc.
. •• • • •••••
.• ••
with th4 omMunityis•....
ceitify4hie information in Section V.'
• •
E3. Attached garage (top of slab) is ❑feet ❑ meters
E4. Top of platform of machinery and/or equipment
servicing the building is ❑ feet ❑ meters
E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accojclance
floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must
SECTION F — PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CEFt WfCATION• ;• •
The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A (without a I'LMIA 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 (7/15)
Replaces all previous editions.
Form Page 3 of 6
ELEVATION' CERTIFICATE
OMB No. 1660-0008
Expiration Date: November 30, 2018
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.
1050 NE 107TH STREET
Policy Number:
City State ZIP Code
MIAMI SHORES Florida 33161
Company NAIC Number
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•Eertificate of '•; ••
Complia0G4/Occupancy Issued ""' •
• •
•••• •• • ••••••
• • .• • • . •
•.••
G7. This permit has been issued for: ❑
G8. Elevation of as -built lowest floor (including
of the building:
G9. BFE or (in Zone AO) depth of flooding at the
G10. Community's design flood elevation:
New Construction ❑ Substantial Improvement
basement)
❑ feet
❑ feet
❑ feet
• •• •....
..•••• • ••. •
•• •• ••• ••
.•...•
•..••• •
• ' ' '
[1 meters Drip: • •. • • • •
building site:
•• • •• • ••.•••
❑ meters D'yme • • •
❑ 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 (7/15)
Replaces all previous editions.
Form Page 4 of 6
ELEVATION CERTIFICATE
BUILDING PHOTOGRAPHS
See Instructions for Item A6.
OMB No. '1660-0008
Expiration Date: November 30, 2.01E
IMPORTANT: In these spaces, copy the corresponding information from Section A.
MINOMPOIMOMNI
FOR INSURANCE CONIPANY USE
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
1050 NE 107TH STREET
Policy Number:
City State ZIP Code
MIAMI SHORES Florida 33161
Company NAIC Number
If using the Elevation
instructions for Item A6.
"Left Side View." When
vents, as indicated in Section
Certificate to obtain
Identify all photographs
applicable, photographs
A8. If submitting
NFIP flood insurance, affix at least 2 building photographs below according to the
with date taken; "Front View" and "Rear View"; and, if required, "Right Side View' and
must show the foundation with representative examples of the flood openings or
more photographs than will fit on this page, use the Continuation Page.
1 ,cl'
U Yr
Hwm
_.. �[ ■
4
�Y
}. rw_ r r s Site
F�}'ad ,`. tea. .
1
Y.':
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Photo One
• •
• • • • • • • • •
• • • •••••
•
• • • • • •
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Photo One Caption FRONT VIEW 8/17/17 Clear Photo One
•5
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ray
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i w ice,, y a-
y
Photo Two
Photo Two Caption RIGHT SIDE VIEW 8/17/17 Clear Photo Two
FEMA Form 086-0-33 (7/15)
Replaces all previous editions.
Form Page 5 of 6
ELEVATION CERTIFICATE
BUILDING PHOTOGRAPHS
Continuation Page
OMB No. 1660-0008
Expiration Date: November 30, 2018
IMPORTANT: In these spaces, copy the corresponding information from Section A.
FOR INSURANCE COMPANY USE
Buirding Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
1050 NE 107TH STREET
Policy Number:
City State ZIP Code
MIAMI SHORES Florida 33161
Company NAIC Number
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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a k_.
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y l
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i (1 a
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•
try • •• •••••
•
•••••• ••••.•
•- •
• • • •
• •• a .•••••
• • • •
Photo Three
Photo Three Caption REAR VIEW 8/17/17 Clear Photo Three
•
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Photo Four
Photo Four Caption LEFT SIDE VIEW 8/17/17 Clear Photo Four
FEMA Form 086-0-33 (7/15)
Replaces all previous editions.
Form Page 6 of 6