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EMD-13 (10/02) MICHIGAN STATE POLICE Emergency Management Division AUTHORITY: 1976 PA 390, as amended COMPLIANCE: Voluntary, but completion necessary to be considered for grant HAZARD MITIGATION GRANT PROGRAM PROJECT APPLICATION FOR EMD USE ONLY Directions: 1. See instructions in the Hazard Mitigation Grant Handbook. 2. Complete all sections. (Boxes will automatically expand as needed.) 3. For home acquisition or elevation projects, complete a “Property Site Inventory Sheet” for each home (available separately). 4. DO NOT use: staples; binders; dividers; inserts or unusual sized pages. 5. Submit to the Mitigation Unit, Emergency Management Division. Application #: Project #: Date Received: A. APPLICANT INFORMATION Name of Organization/Agency: Type of Organization (check one): State Agency Local Government Private Non-Profit Other (explain) Indian Tribe or Authorized Tribal Organization Project Title: B. CONTACT INFORMATION PRIMARY POINT OF CONTACT ALTERNATE POINT OF CONTACT Name: Name: Title: Title: Agency: Agency: Address/P.O. Box Number: Address/P.O. Box Number: City: Zip Code: - Telephone Number: ( Fax Number: ( ) ) - City: ext. Zip Code: - Telephone Number: ( - Fax Number: ( E-mail Address: ) ) - - E-mail Address: C. PROJECT INFORMATION County: Location of Project Township: T Range: R Section: Street Address or Nearest Intersection: Does your community participate in the National Flood Insurance Program? YES NO If YES, enter Community Identification Number: Is the project in a FEMA identified flood area? YES NO If YES, enter FIRM Panel Number: Describe the problem you will be solving. (DO NOT write “see attached”) 1 ext. EMD-13 (10/02) MICHIGAN STATE POLICE Describe the Project Solution IN DETAIL. (DO NOT write “see attached”) D. PROJECT COSTS Federal Share: (up to 75%) Applicant Share: (25%) Project Totals Source of Applicant Share: Grand Total of Project: (100%) COST ESTIMATE BREAKDOWN ITEM UNIT QUANTITY UNIT OF MEASURE (NOTE: Totals MUST equal “Grand Total of Project” amount.) UNIT COST COST ESTIMATE TOTAL COST EXAMPLE: COST ESTIMATE BREAKDOWN ITEM UNIT QUANTITY UNIT OF MEASURE UNIT COST COST ESTIMATE Site Acquisition 1 Home $90,000 $90,000 Warning Siren 2 Siren $15,000 $30,000 100 Hours $100 $10,000 1 Lump Sum $1,000 $1,000 Engineering Plans Public Meeting Common Functional Elements Used for Costs Breakdown are: Project Management; Comprehensive Study; Engineering and Design; Site Acquisition; Construction; Labor, and Other. 2 EMD-13 (10/02) MICHIGAN STATE POLICE E. BENEFIT COST INFORMATION How long will the project continue to solve the problem? Annual Maintenance Costs: For Flood Acquisition or Elevation Projects complete Box A for each structure (Please note, you must also complete a “Property Site Inventory Sheet” for each home - available separately). For other types of projects complete Boxes B and C. BOX A. Flood Acquisition or Elevation Projects Address: Address: Address: Year built: Year built: Year built: Type of structure: (identify 1 or 2 story, with or without basement) Type of structure: (identify 1 or 2 story, with or without basement) Type of structure: (identify 1 or 2 story, with or without basement) Square footage: Square footage: Square footage: First floor elevation: First floor elevation: First floor elevation: Current local construction costs per square footage: Current local construction costs per square footage: Current local construction costs per square footage: BOX B. Damages Before Mitigation (for projects other than flood acquisition or elevation) Physical Damage: What damage is being experienced? List everything that gets damaged. How much does each listed damage cost? (Explain how the cost was determined for each.) What is Damaged Cost of How often does this How was the cost determined Damage damage occur 3 EMD-13 (10/02) MICHIGAN STATE POLICE EXAMPLE: What is Damaged Road Damage Cost of Damage $960 How often does this damage occur Every year Road Damage $8,000 Every 5 years Furniture Warehouse $10,500 Every 5 years Insurance claims for 1 ft. water in warehouse – furnace repairs $500, + loss inventory $10,000 Furniture Warehouse 104,000 Every 20 years Insurance claims for 8 ft. water in warehouse – furnace repairs $4,000, + loss inventory $100,000 Loss of Function Damage: How was the cost determined 3 laborers for 8 hrs @ $15/hr = $360, + 1 backhoe @ $50/hr for 8 hrs. = $400, + 20 yd fill material @ $10 /yd = $200 10 laborers for 24 hrs each @ $15/hr. = $3,600, + 2 backhoes @ $50/hr for 24 hrs = $2,400, + 200 yd. Fill material @ 10/yd = $2,000 (BOX B. continued) When residents lose certain utility services (electric power, potable water, and wastewater), FEMA allows for calculation of damages based on pre-assigned dollar losses for each utility. The calculations take into account the length of service interruption, the number of individuals who lose service, and the type of loss (partial or complete loss of the service). Complete the chart below for each service loss that is experienced. The data will be used to calculate a damage amount. For the electronic version, drop down menus are available under the columns “Service lost” and “Type of loss”, just click on the gray area for the drop down menu. Service lost Type of loss Number or Length of service How often does this (complete or partial loss) residents interruption loss occur impacted 4 EMD-13 (10/02) MICHIGAN STATE POLICE Detour Damage: (BOX B. continued) When roads or bridges are closed, FEMA allows for calculation of damages based on pre-assigned dollar losses for each vehicle detoured. The calculation takes into account the average daily traffic volume (number of cars) that will be detoured, and the length (in time, NOT distance) of the detour (how long will it take each vehicle to route around the detour). Complete the chart below for each detour experienced. The data will be used to calculate a damage amount. Average number of Length (in time) How long is the detour How often do the vehicles that travel the of detour in place detours occur detoured road each day BOX C. Projected Damages After Mitigation Physical Damage After Mitigation: List the projected damages that will continue to occur AFTER completion of the project. How much would each projected damage cost? (Explain how the cost was determined for each.) What may be Cost of How often will this How was the cost of the damage damaged damage damage occur determined Loss of Function Damage After Mitigation: (BOX C. continued) If utility services would continue to be lost after mitigation, complete the chart below for each loss that would be experienced. For the electronic version, drop down menus are available under the columns “Service Lost” and “Type of Loss”, just click on the gray area for the drop down menu. Service Lost Type of Loss Number of Length of Service How often does this (electric power, (complete or partial loss) Residents Interruption loss occur potable water, Impacted and wastewater) 5 EMD-13 (10/02) MICHIGAN STATE POLICE Detour Damages AFTER Mitigation: (BOX C. continued) If detours would continue to occur AFTER mitigation, complete the chart below for each projected detour. The data will be used to calculate a damage amount. Average number of Length (in time) of How long is the detour How often do the vehicles that travel the detour in place detours occur detoured road each day F. ALTERNATIVES CONSIDERED Federal regulations require that credible alternatives must be considered during the decision making process. Please outline alternatives, other than the proposed project, that were considered. Alternative 1. Alternative 2. Alternative 3. Reasons why the proposed project was chosen over the alternatives: How was the alternative chosen? (i.e. Was this strictly a government decision? Was there public participation, public notices, etc.?) G. MISCELLANEOUS PROJECT INFORMATION ENVIRONMENTAL CONSIDERATIONS 1. Are there known environmental concerns associated with the project or known sensitive natural YES NO features that could be impacted by the project? If YES, please explain: 2. What is the name and type of the nearest body of water (lake, pond, river, stream, etc.): 3. Estimate the distance from the nearest part of the project to the nearest body of water: 4. Estimate the distance from the nearest part of the project to a wetland: 5. Estimate the distance from the nearest part of the project to a Great Lakes coastline: 6. Estimate the distance from the nearest part of the project to agricultural land: 7. Is the project near a wilderness area or wildlife refuge? If YES, estimate the distance: 8. Is the project near any known historic structures? If YES, estimate the distance: 6 YES YES NO NO EMD-13 (10/02) MICHIGAN STATE POLICE ENVIRONMENTAL JUSTICE 1. Are there concentrations of low-income or minority populations in or near the project area(s)? YES NO If YES, please explain: 2. Does the project have disproportionately high or adverse effects on low income or minority populations? YES NO If YES, please explain: PROJECT WORK SCHEDULE Please provide a generic timeline (i.e., do not use specific dates) of key activities to complete the project. The performance period of the grant, if awarded, will be established based on the work schedule provided here. Please make sure the work schedule is practical and incorporates sufficient time for administrative activities. Activity Timeframe Activity Complete Construction Plans Bid Letting Construction Final Inspection and Project Completion EXAMPLE: Timeframe 2 months 1 month 2 months 1 month H. EARLY WARNING SIREN INFORMATION Complete the following questions ONLY if the project is for early warning sirens. 1. What is the population of your community? 2. How may sirens does your community currently have? 3. What percentage of the population is currently covered by sirens? 4. How many sirens do you want to purchase with this grant? 5. What percentage will be covered after these new sirens are in place? 6. Provide the following location information for each proposed siren. TOWNSHIP RANGE SECTION STREET ADDRESS OR MAJOR INTERSECTION 7 EMD-13 (10/02) MICHIGAN STATE POLICE I. REQUIRED MAPS, PHOTOGRAPHS, AND ADDITIONAL FORMS The following maps, photographs and additional forms are required to meet environmental review requirements and must be submitted as part of the grant application. If submitting the grant application electronically, electronic maps and photographs must be attached. If submitting the grant application as a hard copy, hard copy maps and photographs must be attached. Failure to submit these documents may result in slower processing of the grant application. Two 8 ½ x 11 maps of the project location: One general map of the project location One localized map highlighting the exact location of the project (if there are multiple addresses each must be highlighted on the map.) One 4x6 photo of the project site. (Multiple photographs may be submitted if so desired.) One 4x6 photo of each affected structure and the year built. One “Property Site Inventory Sheet” for each structure proposed for acquisition or elevation. This is a separate form available from the Michigan State Police, Emergency Management Division. 8 EMD-13 (10/02) MICHIGAN STATE POLICE HAZARD MITIGATION GRANT PROGRAM State of Michigan – Local Disaster Assistance Agreement This certification by the (applicant) shall be effective on the date signed by the applicant. It shall apply to all assistance funds provided by or through the State to the applicant under the Hazard Mitigation Grant Program, pursuant to Section 404 of P.L. 93-288, as amended, as a result of a Presidentially-declared disaster occurring within the state of Michigan under the Federal Emergency Management Agency declaration number FEMA-1413-DR-MI. The designated representative of the applicant certifies that: 1. He/she has legal authority to apply for assistance on behalf of the applicant. 2. The applicant is aware that the limited funding available for mitigation requires costsharing on the basis of 75 percent federal and 25 percent non-federal contributions unless otherwise specified by the State. 3. The applicant may be required to provide the full non-federal share for such mitigation activities. 4. The local cost share funds will be available within the specified time. 5. The applicant will comply with all applicable codes, standards, and permit requirements as pertain to this project and agrees to provide maintenance as appropriate. Designated Representative's Signature: Name (Typed) Signature Title 9 Date