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Home My Public Portal AboutSixth Av_14FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM .EVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. O.M.B. No. 3067-0077 F.* • es- n eee�laera 5 SECTION A - PROPERTY OWNER INFORMATION For insurance Company Use: BUILDING OWNER'S NAME Policy Number BUILDIN,2EETADD (Including Unit, Suite, and/or g_ p,) JO P.O. ROUTE AND BOX NO. � fri 4 2 Company NAIC Number 3/1 Pzce E PROPERTY DESCRIPTION (ot qnd Block Num ers, Tax Parcel Number, Legal Description, etc.) L BUIJ,�NCLg E (e.g., Residential, Non - residential, Addition, Accessory, etc. Use Comments area if necessary.) LATITUDE/LONGITUDE (OPTIONAL) ( #/# °- ##'- ##.##" or##. 110) HORIZONTAL DATUM: LI NAD 1927 [1 NAD 1983 SOURCE: L GPS (Type): 11 USGS Quad Map U Other: SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 131. NFIP COMMUNITY NAME & COMMUNITY NUMBER 71c �1Yi� /7f B2. COUNTY NAME 77-4M 83. STATE�14 1 B4. MAP AND PANEL 1NUMBER / ;764 �l B5. SUFFIX c 86. FIRM INDEX DATE 6/o�gg B7. FIRM PANEL EFFECTIV� REVI ED DATE 1 6/174'6 B8. FLOOD ZONES d4 B9. BASE FLOOD ELEVATION(S) /Z B10. Indicate the source o e Base Flood Elevation (BFE) data or base flood depth entered in B9. LI FIS Profile 1_ IRM L1 Community Determine 1_1 Other (Describe): B11. Indicate the elevation datum used for the BFE in B9: 1 1GVD 1929 U NAVD 1988 L Other (Describe) � B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? L1 Yes 1 =1 Jo Designation Date- SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: L1Construction Drawings* LJBuilding Under Construction* L inished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number S (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 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 calculatio . U the spa provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion. Datum /1/f FJ ? Conversion /Comments Elevation reference mark used Does the elevation reference mark used appear on the FIRM? I I Yes 1 ]No ❑ a) Top of bottom floor (including basement or enclosure) ❑ b) Top of next higher floor ❑c) Bottom of lowest horizontal stnichiral member (V zones only) ❑d) Attached garage (top of slab) ❑e) Lowest elevation of machinery and /or equipment �� ft servicing the building (Describe in a Comments area.) ❑ f) Lowest adjacent (finished) grade (LAG) r • 3— ft•(m) ❑ g) Highest adjacent (finished) grade (HAG) ❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade ❑ i) Total area of all permanent openings (flood vents) in C3.h sq. in. (sq. cm) /4 . o ft.(- i2(Q ft .(m) 4/4 • ft.(m) hick. ft(m) . T ft.(m) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATI 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. 1 understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. CERTIFIER'S NAME TITLE ,'TT / -)/A/oz es COMPANY NAME LICENSE NUMBER 2Z Ag ADDRESS / c vE CITY SIGNATUR // DAT FEMA Fo 1 -31, January 2003 6 a3 ST TtX .5/ ,PIP E TELEPHONEg 2. 46 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS Imrvrt ir+ry i: in inese spaces, copy the corresponding information from Section A. For Insurance Company Use: BUILDING STR E ADD SS {Including A Unit, Suite, an or B No , R P.O. ROUTE AND BOX NO. Policy Number CITY 775 2X0P Sj 5/ DE 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 )4'!G l'011-4P. 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 E1. 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 I I I ft.(m) L_JJin.(cm) I -I above or 1_1 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 1 1 ft•(m) I Iin.(cm) above the highest adjacent grade. E4. The top of the platform of machinery and /or equipment servicing the building is L_ J ft. (m) L_L_1 in. (cm) 1_1 above or L below (check one) the highest adjacent grade. (Use natural grade, if available.) E5. 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? I_1 Yes I 1 No IJ 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 L 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. IJ 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. I IA community official completed Section E for a building located in Zone A (without a FEMA - issued or community- issued BFE) or Zone AO. G3. 1 I 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. LI New Construction L Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building is: . ft.(m)Datum: G9. BFE or (in Zone AO) depth of flooding at the building site is: LOCAL OFFICIAL'S NAME COMMUNITY NAME SIGNATURE . ft.(m)Datum: TITLE TELEPHONE COMMENTS DATE FEMA Form 81 -31, January 2003 I I Check here if attachments REPLACES ALL PREVIOUS EDITIONS