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DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY D.n+.B.No.166UGIS <br /> PROPERTY INFORMATION FORM Expires February 28,2014 <br /> PAPERWORK BURDEN DISCLOSURE NOTICE <br /> Public reporting burden for this data collection is estimated to average 1,63 hours per response. The burden esumate includes the time for reviewing instructions, <br /> searching existing data sources,gathering and maintaining the needed data,and Completing and sulmitur,the form. This collection is required 10 Obtain or retain <br /> beni you are not required to respond to this collection of information unless a valid OMB control number is Displayed on this fon,. Send romeni regarding the <br /> accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management, Department of Homeland SecudN,Federal <br /> Emergency Management Agency,1800 South Bell Street,Arlington,VA 205983005, Paperwork Reduction Project(1660 all NOTE: Do not send your completed <br /> form to this address. <br /> This form may be completed by the property owner,property owner's agent,licensed land surveyor,or registered professional engineer to suppon a request for a <br /> Letter of Map Amendment(LOMA),Conditional Letter of Map Amendment(COMM,Letter Of Map Revision Based a FIII(LOMR-F),or Condllional Letter Of Map <br /> Revision Based on Fill(CLOMR F)for existing or proposed,single or multiple lots/structures. In order no process your request,all information on this form must be <br /> completed In its entirety,unless stated as optional. Incomplete submissions will result In processing delays. Please check the item below that describes your request'. <br /> ❑ LOMA A letter from DHS FEMA stating that an existing structure or parcel of land that has not been <br /> elevated by fill(natural grade)would not be inundated by the b rse flood. <br /> ❑ CLOMA A letter from DHS-FEMA stating that a proposed structure that is not to be elevated by fill(natural <br /> grade)would not be inundated by the base flood if built as proposed. <br /> ® LOMR-F A letter tram OHS FEMA stating that an existing structure or parcel of land that has been elevated by <br /> fill would not be inundated by the base flood. <br /> A letter from DHS-FEMA stating that a parcel of land or proposed structure that will be elevated by <br /> ❑ CLOMR-F till would not be inundated by the base flood if fill is placed on the parcel as proposed or the <br /> structure is built as proposed. <br /> Fill is defined as material from any source(including the subject property)placed that raises the ground to or above the Base Flood Elevation(BFE). The common <br /> con•.Gnctlon practice of removing unsuitable existing material(topsoil)and backfilling with select structural material Is not considered the placement of fill 11 the <br /> once does not alter the existing(natural grade)elevation,which is at or above the BEE. FIII that is placed before the date of the first National Flood Insurance <br /> Prai INFIP)ma,showing In,area In a SPecial Flood Hazard Area ISFHA)Is considered natural grade. <br /> tlxs fill been placed on your property to raise <br /> ground that was previously below the BEE? ® Yes ❑ No Ifyec,whenwas fill placed? 712014 <br /> month/year <br /> Will fill be placed on your property to raise <br /> ,,cord that is below the SFE? ❑ Yes' ® No Ifyee,whenwill fill be placed? / <br /> month/year <br /> If yes,Endangered Species Act(ESA)compliance must be documented to FEMA prior to issuance _ <br /> of the CLOMR-F determination Iplease refer page 4 to the MT-1 instructions). <br /> 1. Street Address of the Property(if request is for multiple structures or units,please attach additional sheet referencing each address ar9 enter <br /> street names below): <br /> 27209 Jamison Road.Webster,WI 54893 <br /> 2. Legal description of Property(Lot,Block,Subdivision or abbreviated description from the Deed): <br /> Deed v.611, p.446; Lot it of survey D-529 <br /> 3. Are you requesting that a flood zone determination be completed for(check one)'. <br /> ® Structures on the property? What are the dates of construction?08.1014(N4M/YYYY) <br /> ❑ A portion of land within the bounds of the property?(A certified metes and bounds description and map of the area to be <br /> removed,trended by a licensed land surveyor or registered professional engineer,are required.For the preferred format of <br /> metes and bounds descriptions,please refer to the MT-1 Form l instructions.) <br /> ❑ The entire legally recorded property? <br /> i 4. Is this request for a(check one): <br /> ;Cj ❑ Single structure <br /> ❑ Single lot <br /> C ® Multiple structures(How many Structures are involved In your request?List the number: 3) <br /> x ❑ Multiple lots(How many lots are involved in your request?List the number: ) <br /> @1F- FEMA Fon, 006-0-26,PFB 11 Property Information Form MT-1 Form 1 Page 1 of 2 <br />