Fillable SHOP-Project-Description - SHOP Project Description_043019m

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SHOP-Project-Description - SHOP Project Description_043019m

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Page1of2
S
AFER
H
OUSINGFOR
O
AKLAND
P
ROGRAM
(SHOP)
ProjectDescription
TheDesignfirmmustcompleteandsubmitthisformwiththeretrofitplansandcalculationstoSHOPattheemailor
addressabove.Anychangestotheprojectdesignmustbedocumentedbytheengineer/contractoronarevisedform.
1.
VisibleExteriorChanges:
Willanyvisibleexteriorchangesresultfromthisretrofitprojectoranyother
concurrent,non‐seismicactivities?
NO YES*
*Describeanyvisibleexteriorchangesbelowandensurethattheyareclearlydepictedintheschematics
anddrawings.Statewhetheranyrelevantrepairorreplacementwillbeperformedin‐kindand/or
whethervisiblechangeswillbereversible.
2.
RequiredSeismicActivities:
ArealltherequiredmeasuresdescribedinAppendixChapterA4ofthe
2016CEBCandsectionBoftheSHOPEngineeringRequirementsincludedinyourscopeofwork?
YES NO*

*Ifanyoftheabovearenotapplicabletoyourproject,explainwhy:
3. OptionalSeismicActivities:
Indicateanddescribeanyadditionalseismicmeasuresincludedinyour
scopeofworkbeyondtheminimumrequirementsofChapterA4.

D
EPARTMENT OF
H
OUSING AND
C
OMMUNITY
D
EVELOPMENT
R
ESIDENTIAL
L
ENDING AND
R
EHABILITATION
S
ERVICES
250
FRANK
H.
OGAWA
PLAZA,
SUITE
5313
OAKLAND,
CALIFORNIA
94612-2034
ResidentialLending@oaklandnet.com

/238‐3598
S
ITE
A
DDRESS
:  P
ROJECT
#: 
P
ROPERTY
O
WNER
:

D
ESIGN
F
IRM
: 
P
HONE
:
Page2of2
4. Non‐SeismicActivities:
Willanynon‐seismicworkbeconductedatthesametimeastheretrofit?
NO YES*
*Clearlydescribenon‐seismicworktobeconductedconcurrentlywiththeretrofitunderaseparate
permit.Ifthebuildingismorethan45yearsold,includePlans,Schematics,andPhotographsforEHP
Reviewasaseparateattachment.
5. PermitApplicantCertification:
Mysignaturebelowconfirmsthefollowing:
Thedescriptionaboveincludesallworkthatwillbeconductedduringorconcurrentlywiththe
seismicretrofitofthisproperty.
Ifanynon‐seismicornon‐reimbursableworkisplanned,itwillbecoveredunderseparatepermit(s).
AnychangestothisscopeofworkwillbesubmittedtotheSHOPOfficeusingarevisedversionofthis
formandupdatedplans/drawings/picturesasisappropriatebeforeanyunapprovedactivitiesbegin.
NoadditionalactivitieswillbeconducteduntildesignrevisionsareapprovedbyFEMAandSHOP.
I/weunderstandthatanyactivitiesconductedwithoutSHOPapprovalpriortoSHOPreimbursement
andprojectclose‐outmayresultinpreviouslyeligiblecostsbeingdeniedreimbursement.
CompletedBy:
EngineerofRecord Contractor

Signature Date
SHOP STAFFUSEONLY
DateReceived:________________Reviewedby:______________________________Ext:_________
Approved?Y/NDate:_________________ApplicationSubmitted:_________________
Comments:_______________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_________________________________________________________________________________________________
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SHOP-Project-Description - SHOP Project Description_043019m

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Completed 26 February 2020

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