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Attachment 3 <br /> PROJECT WORKSHEET SAMPLE <br /> U.S. DEPARTMENT OF HOMELAND SECURITY <br /> FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 1660-0017 <br /> PROJECT WORKSHEET <br /> PAPERWORK BURDEN DISCLOSURE NOTICE <br /> Public reporting burden for this form is estimated to average 90 minutes per response. Burden means the time, effort and financial <br /> resources expended by persons to generate, maintain, disclose, or to provide information to us. You may send comments <br /> regarding the accuracy of the burden estimate and or any aspect of the collection, including suggestions for reducing the burden <br /> to: Information Collections Management, U. S. Department of Homeland Security, Federal Emergency Management Agency, 500 <br /> C Street, SW, Washington, DC 20472, Paperwork Reduction Project (OMB Control Number 1660-0017). You are not required to <br /> respond to this collection of information unless a valid OMB number appears in the upper right corner of this form. NOTE: Do not <br /> send our completed form to this address. <br /> DISASTER PROJECT NO. PA ID NO. DATE CATEGORY <br /> F _ R <br /> DAMAGED FACILITY WORK COMPLETE AS OF: <br /> • <br /> % <br /> SUBRECIPIENT COUNTY <br /> LOCATION LATITUDE LONGITUDE <br /> DAMAGE DESCRIPTION AND DIMENSIONS <br /> SCOPE OF WORK <br /> Does the Scope of Work change the pre-disaster conditions at the site? ❑ Yes ❑ No <br /> Special Considerations issues included? ❑ Yes ❑ No Hazard Mitigation proposal included?❑ Yes ❑ No <br /> Is there insurance coverage on this facility? ❑ Yes ❑ No <br /> PROJECT COST <br /> Ill CODE NARRATIVE QUANTITY/UNIT UNIT PRICE COST <br /> ■- I <br /> TOTAL COST <br /> PREPARED BY TITLE SIGNATURE <br /> SUBRECIPIENT REP. TITLE SIGNATURE <br /> FEMA Form 90-91,FEB 06 REPLACES ALL PREVIOUS EDITIONS. <br /> Public Assistance Grant Agreement Page 21 of 21 City of Everett, D20-122 <br />