2015/02/13 - OTHER - (NA) - Note

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In addition to this form(MT-1 Form 1),please complete the checklist below. ALL requests must include one copy of the following: ® Copy offhe effective FIRM panel on which the structure and/or property location has been accurately plotted)proper,inadvertently located in the NF IP regulatoryfloodwaywill require Se"Ad a of MT-1 Form 3) ® Copy of the Subdivision Plat Map for the property(with recordation data and stamp of the Rocorde/s Office) OR ® Copy of the Property Deed(with recordation data and stamp of the Recorder`,Office),oecpmp ded by a tar asesso(s map or other certlfied map showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street intersection that is shown on the FIRM panel. Form 2—Elevation Form. If the request is to remove the structure,and an ElevationCenificate has already been completed for this property,it may be submitted in lieu of Form 2. If the request is to remove the entire legally recorded prcpi Or a portion thereof,the lowest lot elgV tidp must be provided on Form 2. Please include a map scale and North arrow on all maps submitted. For Loss Fs and CLOMR-R,the following must be submitted in addition to the items listed above: ® Form 3—Community Acknowledgment Form For CLOMR Fs,the following must be submitted in addition to the LLems listed above: ❑Documented ESA compliance,which may include a copy of an Incidental Take Permit,an Incidental Take Statement,a"not likely to adversely affect" determination from the National Marine Fisheries Service INMFS)or the U.S.Fl sh antl Wildlife Service(USF WS),or an official letter from NMFS or USFWS concurring that the project has"No Effect-On proposed or listed species or designated critical habitat.Please refer to the MT-1 instructions for additional information. Please do not submit original documents. Please retain a copy of all submitted documents for your records. OHS-FEMA encourages the submission of all required data in a digital format(e.g.scanned documents and images on Compact of,,Co). Digital submissions help to further DHS-FE MA's Digital Vision and also may facilitate the processing of your request. Incomplete submissions will result In processing delays.For additional information regarding this form,including where to obtain the supporting documents listed above,please refer to the MT-1 Form Instructions located at hit It1 / / /fh /dl cot-15bim. Processing Fee(see instructions for appropriate mailing address;or visit http'//www.forma.govy1firedifirrin fees.shtm for the most current fee schedule) Revised fee schedules are published periodically,but no more than once annually,as noted in the Federal Register. Please note: single/multiple lots)/structure(s)LOMAs are fee exempt. The current review and processing fees are listed below: Check the fee that applies to your request: ❑$325(single lot/structure LOMR-F following a CLOMR-F) $425(single lot/structure LOMR-F) ❑$500(single lot/structure CLOMA or CLUMP F) $700(multiple lot/structure LOMB F following a CLOMR F,or multiple lot/structure GLORIA) ®$800(multiple lot/structure LOMR-F or CLOMR-F) Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money Order payable to. National Flood Insurance Program. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Applicant's Name(required): Brian Lorene, Company(if applicable)'. Mailing Address(required): Daytime Telephone No Irequiredf, 612-816-3377 1056116"Street West over Grove Heights,MN SSW 6 Fax No.(optional)'. E-Mail Addresa(optional):emeh:0 Bb,, poi here you may receive correspondence I±ctroggqnically at:M1e ems)atltlress providetl): i /___ �/ `.n �. /e-StgGr/ S,irboun,of A,pl,,bn,jecruirepl Gate lmouver.; i �/ �� 0;iS-FEMA Penn 006-0-26,FEB 11 Property Information Form I Form 1 Page 2 of 2..