D19-1004 Kittitas County Ryegrass Coulee

Home Browse Search

FFY18 Fire Management Assistance Grant Agreement Page 21 of 22 Kittitas, County of, D19-1004 Attachment 3 PROJECT WORKSHEET SAMPLE DEPARTMENT OF HOMELAND SECURITY O.M.B. NO. 1660-0017 FEDERAL EMERGENCY MANAGEMENT AGENCY Expires April 30, 2013 PROJECT WORKSHEET PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 90 minutes per response. Burden means the time, effort and financial resources expended by persons to generate, maintain, disclose, or to provide information to us. You may send comments regarding the burden estimate or any aspect of the collection, including suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (OMB Control Number 1660-0017). You are not required to respond to this collection of information unless it displays a valid OMB number. NOTE: Do not send your completed questionnaire to this address. DISASTER PROJECT NO. PA ID NO. DATE CATEGORY FEMA - -DR- DAMAGED FACILITY WORK COMPLETE AS OF : % APPLICANT COUNTY LOCATION LATITUDE LONGITUDE DAMAGE DESCRIPTION AND DIMENSIONS SCOPE OF WORK Does the Scope of Work change the pre-disaster conditions at the site? YES NO Special Considerations issues included? YES NO Hazard Mitigation proposal included? YES NO Is there insurance coverage on this facility? YES NO PROJECT COST ITEM CODE NARRATIVE QUANTITY/UNIT UNIT PRICE COST TOTAL COST PREPARED BY TITLE SIGNATURE APPLICANT REP. TITLE SIGNATURE FEMA Form 009-0-0-7 APRIL 2013 REPLACES PREVIOUS EDITION Form 90-91