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Home My Public Portal AboutLighthouse Ln_9""„,� GIaGRVCI`f4 T MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION O.M.B. No. 3067 -0077 Expires July 31, 2002 For Insurance Company Use: BUILDIN OWNER'S E 14 /TC! i r,AI BUILDING STREET 4DDRESS (Ind ing Apt it, Su' d /or Bldg. No.) OR P.O. ROUTE AND BOX NO. /5- STREET (1 & L if-dlitri C C 7 A, ('2 2 PROPERTY DESCRIPTIO (Lot and Block Numbers, T Pa I er, Legal Description, etc.) BUILDING. .. Residential, Non - residential, Addition, Accessory, eta Use a Comments area, necessary.) LATITUNGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: LI GPS (Type): ( ##° - ##' -44.W or ##.#1'####') L NAD 1927 LJ NAD 1983 LJ USGS Quad Map L j Other. Policy Number Company NAIL Number IL PZ�ODE 3i e SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER B2. COUNTY NAME B3. STATE . A B4. MAP AND PANEL NUMBER /3564 oar/ B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. FIS Profile �IRM 1_1 Community Determined 1 !Other (Describe): 311. Indicate the elevation datum used fcr the BFE in B9: �_ GVD 1929 11 NAVD 1988 1_1 Other (Describe): 312. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 1_1 Yes (- to Designation Date: B5. SUF IX 86. FIRM INDEX DATF 6/0166 87. FIRM PANEL EFFECTIVE/REVI ED DATE (1/7/ 6 88. FLOOD ZONE(S) 18 B9. BASE FLOOD ELEVATION(S) (Zone AO, use depth of flooding) SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) :1. Building elevations are based on: LJConstruction Drawings* 1 1Building Under Construction* Lr finished Construction `A new Elevation Certificate will be required when construction of the building is complete. :2. Building Diagram Number 6- (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.) :3. Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, AR /AE, AR/A1 -A30, AR /AH, AR /AO 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 )VC'i'j zi. Conversion/Comments Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑ a) Top of bottom floor (including basement or enclosure) /7 ...1 . ft.fFr} m ❑ b) Top of next higher floor ale`. ft.(m) 00 ❑ c) Bottom of lowest horizontal structural member (V zones only) ft.(m) o S CI d) Attached garage (top of slab) ft.(m) ❑ e) Lowest elevation of machinery and /or equipment QQ servicing the building (Describe in a Comments area.) J. . SG ft-( ❑ f) Lowest adjacent (finished) grade (LAG) G .1r ft.(m) 2 ❑ g) Highest adjacent (finished) grade (HAG) 6 • ft.trrer _ 15 U J ❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade O ❑ i) Total area of all permanent openings (flood vents) in C3.h sq. in. (sq. cm) LJ Yes SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION Phis certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. ' certify that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available. understand that an false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. Adir Air I IL.. LICENSE NUMBER z :ERTIFIER'S NAME TITLE COMPANY NAME \DDRESS iIGNATURE C7-7cg491100 Abe' 4- A =MA Fnr.. A1-11 .11 11 nn TELEPHONE - SPF RFVFRCF G1rIF FrIP r'r1NTi Ji i nrIN PPPI Ar:Fs Al I PPPVIC I IC Fr1mnni$ IMPORTANT: In these spaces, copy the corresponding information from Section A. `?UILDING STREET 6DDRESS In ding Apt. nit, Su' nd/or B g. No.) OR P.O. ROUTE AND BOX NO. CITY For Insurance Company Use: Policy Number rI 4l // SA 3/ P5E Icipmpany SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) NAI6-Number Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner. COMMENTS C3 .e\= e C Go /3 I 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 (including basement or enclosure) of the building is LI_I ft.(m) 1_1_lin.(cm) 1r1 above or L 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 I1.__1 ft(m) L LJin.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form. E4. For Zone AO only. If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? 1_1 Yes 1L No l_l 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 REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE COMMENTS DATE TELEPHONE I-1 Check here if attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) ie local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete actions A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. 1. LJ 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.) 2. IJ A community official completed Section E for a building located in Zone A (without a FEMA- issued or community - issued BFE) or Zone AO. 3. LJ The following information (Items G4 -G9) is provided for community floodplain management purposes. A. PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATE CEA IFICATE OF CQ&Th IANCE/OCCUPANCY ISSUED '. This permit has been issued for 1 New New Construction Ll Substantial Improvement 3. Elevation of as -built lowest floor (including basement) of the building is: . ft.(m) Datum: ,. BFE or (in Zone AO) depth of flooding at the building site is: . ft.(m) Datum: OCALOFFICIALS NAME TITLE OMMUNITY NAME TELEPHONE GNATURE MINENTS DATE I I Check here if attachments \A Fnrm R1_41 .1111 nn RFPI Gr.PR Al 1 PRPVICI IC Fnrnnr s