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FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Important: Read the instructions on pages 1- 7.
O.M.B. No. 3067 -0077
Expires December 31, 2005
SECTION A - PROPERTY OWNER INFORMATION
BUILDING OWNER'S NAME
ANDY BURNS
BUILDING STREET ADDRESS (Including Apt, Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
#86 VAN HORNE STREET
For Insurance Company Use:
Policy Number
Company NAIC Number
CITY STATE
TYBEE ISLAND, GA
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
LOT 33 -B, CAPTAIN'S ROW
ZIP CODE
31328
BUILDING USE (e.g., Residential, Non - residential, Addition, Accessory, etc. Use a Comments area, if necessary.)
RES
LATITUDE/LONGITUDE (OPTIONAL)
( ##° - ##' - ##.##" or ##.#####°)
HORIZONTAL DATUM:
❑ NAD 1927 ❑ NAD 1983
SOURCE: ❑ GPS (Type):
❑ USGS Quad Map ❑ Other.
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
81. NFIP COMMUNITY NAME & COMMUNITY NUMBER
TYBEE ISLAND 135164
B2. COUNTY NAME
CHATHAM
B3. STATE
GA
B4. MAP AND PANEL
NUMBER
135164 0001
85. SUFFIX
C
B6. FIRM INDEX DATE
6/17/86
B7. FIRM PANEL
EFFECTIVEIREVISED DATE
6/17/86
B8. FLOOD ZONE(S)
A8
69. BASE FLOOD ELEVATION(S)
(Zone AO, use depth of flooding)
14
610. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
❑ FIS Profile ® FIRM ❑ Community Determined ❑ Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: ® NGVD 1929 ❑ NAVD 1988 ❑ Other (Describe):
B12. Is the building located in a Coastal Banier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑ Yes ® No Designation Date
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction* ® Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Building Diagram Number 1(Select the building diagram most similar to the building for which this certificate is being completed - see pages 6 and 7. If no diagram
accurately represents the building, provide a sketch or photograph.)
C3. Elevations — Zones Al -A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, AR/AE, AR/A1 -A30, AR/AH, AR/A0
Complete Items C3. -a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from the datum used for the BFE in
Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion calculation. Use the space provided or the Comments area of
Section D or Section G, as appropriate, to document the datum conversion.
Datum NGVD 29 Conversion/Comments
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑ Yes ® No
o a) Top of bottom floor (induding basement or endosure) 14. 0 ft.(m)
o b) Top of next higher floor 22.3 ft.(m)
o c) Bottom of lowest horizontal structural member (V zones only) NA . _ft.(m)
o d) Attached garage (top of slab) 14. 0 ft.(m)
o e) Lowest elevation of machinery and/or equipment
servicing the building (Describe in a Comments area) 14.2 ft.(m)
0 f) Lowest adjacent (finished) grade (LAG) 13.4 ft.(m)
o g) Highest adjacent (finished) grade (HAG) 13. 9 ft.(m)
O h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade 0
O i) Total area of all permanent openings (flood vents) in C3.h sq. in. (sq. cm)
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
I certify that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
CERTIFIER'S NAME J. WHITLEY REYNOLDS LICENSE NUMBER 2249
TITLE LAND SURVEYOR COMPANY NAME
ADDRESS
636 STEPH
SIGNA .'E
FEMA Fo ' 81 -31, Jan
CITY STATE
SAVANNAH GA
DATE TELEPHONE
9/15/05 912- 352-0464
ZIP CODE
31405
See reverse side for continuation. Replaces all previous editions
IMPORTANT: In these spaces, copy the corresponding information from Section A.
BUILDING STREET ADDRESS (Including Apt, Unit, Suite, ands g. No.) OR P.O. ROUTE AND BOX NO.
#86 VAN HORNE STREET
CITY STATE ZIP CODE
TYBEE ISLAND GA 31328
For Insurance Company Use:
Policy Number
Company NAIC Number
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
COMMENTS
C3.e) = NC PAD
❑ Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)
For Zone AO and Zone A (without BFE), complete Items El through E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR -F,
Section C must be completed.
El. Building Diagram Number _(Select the building diagram most similar to the building for which this certificate is being completed — see pages 6 and 7. If no diagram accurately
represents the building, provide a sketch or photograph.)
E2. The top of the bottom floor (induding basement or enclosure) of the building is _ ft.(m) _in.(cm) ❑ above or ❑ below (check one) the highest adjacent grade. (Use
natural grade, if available).
E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is _ ft.(m) _in.(cm) above the highest adjacent
grade. Complete items C3.h and C3.i on front of form.
E4. The top of the platform of machinery and/or equipment servicing the building is _ ft.(m) _in.(cm) ❑ above or ❑ below (check one) the highest adjacent grade. (Use
natural grade, if available).
E5. For Zone AO only: If no flood depth is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance?
❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G.
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property owner or owner's authorized representative who completes Sections A, B, C (Items C3.h and C3.i only), and E for Zone A (without a FEMA -issued or community-
issued BFE) or Zone AO must sign here. The statements in Sections A, B, C, and E are correct to the best of my knowledge.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVES NAME
ADDRESS
CITY
STATE ZIP CODE
SIGNATURE
DATE TELEPHONE
COMMENTS
❑ Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C (or E), and G of this Elevation
Certificate. Complete the applicable item(s) and sign below.
G1. ❑ The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, engineer, or architect who is authorized by state
or local law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.)
G2. ❑ A community official completed Section E for a building located in Zone A (without a FEMA - issued or community- issued BFE) or Zone AO.
G3. ❑ The following information (Items G4-G9) is provided for community floodplain management purposes.
G4. PERMIT NUMBER
G5. DATE PERMIT ISSUED
G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED
G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement
G8. Elevation of as -built lowest floor (induding basement) of the building is:
G9. BFE or (in Zone AO) depth of flooding at the building site is:
_. _ft.(m)
Datum:
Datum:
LOCAL OFFICIAL'S NAME
COMMUNITY NAME
SIGNATURE
COMMENTS
TITLE
TELEPHONE
DATE
❑ Check here if attachments
FEMA Form 81 -31, January 2003
Replaces all previous editions