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Home My Public Portal AboutELEVENTH TER_2.pdfFEDERAL. EMERGENCY MANAGEMENT AGENCY NATIONAL_ KOOD INSURANCE PROGRAM ELEVATION CERTIFICATE O.M.B. No. 3067-0077 F_xpires July 31, 2002 Important: Read the instructions on pages 1 - 7. SECTION A -PROPERTY OWNER INFORMATION Fa Jripurence Company use: BUILDING STREET ADDRESS Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Grtpahy i PROPEbqy DESCRIPTION (Lot and Numbe ax Parcel Numb Legal Des do etc.) BUILDIResld ril !, an rest entla , Mclition, Accefsory, etcI Ise a mments area, if ec 9ssary.) LATITUDEILONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: LI GPS (Typo): or t/# rfii#iktl°) (_J NAD 1927 u tD 1983 u tJSGS Quad MapJ Other: SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION EW MAP AND PANEL 1 85, FF 86. I IN E9. BASE FLOOD ELEVATION(S) NUMBER PAT4 EFFECTIVE/ EVIS Q PATE Zp S) (Zone AO, use depth of flooding) 1 V o L c 6 i7 T4s !7 B10 Indicate the source of the ase Flood Elevation (BFF) data or base flood depth entergq In 09. !_! FIS Profile IRM !_! Community pet" fined Other tDeacrll?q): 1311. Indicate the elevation datum used for the BFE in B9: I, NGVD 1928 I._1 NAVD 1980 1`1 Othpr (P9§cribe): 812. is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwlsq Prot@ctgd Argf (OPA)? I_I Yes I—I No Designation Date: SECTION C - BUILDING ELEVATION INFORMATION (SURVFY REQUIRED) Ci. Building elevations are based on: I_IConstruction Drawings* I—IBuilding UnderCppotructiopt (_ INl hed Construction ",A new Elevation Carlificale will be required when construction of the building is cornpletq. C2. Building Diagrarn Number _ (Select the building diagram most similar to the building for yvhigh thi& ¢grtifjcate ig being completed -see pages 6 and 7. It no diagram accurately represents the bullding, 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-AIU, AR/AH, AR/AO Complete Items C3.a-I below according to the butidina diagram specified In Item C2,5141@ thq-0414!Ri NSgd• If the datum is different from the datum used for the BFE in Section B, convert the datum to that used for the BFE. Sh9w Meld Mq##uraments and datum conversion calculation. use the space provided or the Comments area pf Section D or Secoon G, w eppraprioly, tp g9pument the datum conyersion. Datum Conversion/Comments Elevation reference mark used Doe$ the elevation reference rnark us0 appopr an tho FIRM Yes tvo ❑ a) Top of bottom floor (including basement or enclosure) /(*J . � h.` , -gL M U b) Top of next higher floor /� h. V OR O c) Bottom of lowest horizontal structural member (V zones only) (t.(Mr I &X YE ❑ d) Attached garage (top of slab)LU U e) Lowest elevation of machinery and/or equipment i * t;o. 22a9 servicing the building (Describe in a Comments area.) ft.(t y a ❑ f) Lowest adjacent (finished) grade (LAG)n,() 2 $ v y0 Q g) Highest adjacent (finished) grade (HAG) 442 . �(t#ftH w SUR�1� Q h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade d H771 E 4 t D 0 Total area of all permanent openings (flood vents) in C3.h D sq. in. (sq. cm) ig SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect outhol44Q4 by Igyir 19 �vrtlfy elevation information. I certify that the information if) Soclions A, 8, and C on this cats ficate represents my bes(effrar(s to intgrprgf (ho data a yailable. l understand that any false statement may be punishable byfine orim risonment under 18 U. S. Code, Section 1001. -.-___L _�- -_ �_ . , S yam_ FFItiAA rm, 7 II nn CFF RFI/FRCF AMP MR r'r)NTiNI IATinN � RFPI Ar -FA AI I PRFVIrU !C r=rllTlrinlC IMPORTANT: In these spaces, copy the corresponding Information from Section A. FQr IflSurlmco Company Use: BUIL DING TREET AD RE LI cludin A ., UniE, Suits, allor SM9. No.) OR P.O. ROUTE AND BOX NO. Perla f jumbar CITY STATE P COD1» ny 011 NurriFer SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenticompany, building owner. COMMENT _ LJ Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZQN9 AQ AND ZONI~ A (WITHOUT SFE) For Zone AO and Zona A (Without 6FE), complete items E1. through E4. If the Elevation Cprllflc 4+ll ig IFtt@ftdt?4 for 499 as supporting information for a t -OMA or LOMB -F, Section C must be complol:0- E1. Building Diagram Number (Select the building diagram most similar to tho buikting for Which Ihl§ p9rpflcate is being completed — see pages 6 and 7. If no diagram accurately represents the building, providg a sketch or photograph.) E2. The top of the bottom floor (including basement or enclosure) of the building is 1_1_1 ft.(m) t�1jtn.(cm) _� 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 of @lov064 AoAF (@I@Y0990 0) 4f the Ouilding is lJ l ft.(m) 1_1_1in.(cm) above the highest adjacent grads. Compigto Items C3.h one G3•i go NgAJ Qf forfrt. E4- For Zone AO only: If no good depth number is available, is the fop of the bottom floor 019yotgo In #cWr0gnq§ with tho community's —_ floodplain management ordinance? L_A Yes_ A-1 No 1 1 Unknown. The local official must cceertlU this Information in Section G. -- SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) GERTIFIGATION The property owner or owner's authorized representative who completos Sectlong A. B, C (114mo 03•It #hq G3,1 poly), and E for Zone A (without a FEMA-i$sued of community -issued 6FE) or Zone AO must sign harp. Thq stafgmgrlfg In , QgPpnq A, A C, ancf Fare correct to the PITO eEsRt of�Y_knowlad e. OR OWNER'S AUTHORIZED REPfIESENITATIVES NAME -3TGHATUR DATE TPF:PI1ONE �OMbfE11T SECTION G - COMMUNITY INFORMATION The local official who is authorized by law or ordinance to edminist¢r the community's floodPiPln rltsnpg9mgrit Ordinance can complete Sections A, S, C (a( E), and G of this Elevation Certificate. Complete the applicable item(a) phj gi&n 0gJgW Gt. l�J The information in Section C was taken (ram other documentation that has peen signgq gn(•pmPagggd Py p licensed surveyor, engineer, or architect who is authorized by state or local taw to certify olovation informgtigq,. (In44t@ the gaurce end 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 FEMA46s1-1e4 or community -Issued SFE) or Zone AO. G3. 1-1 The following information (items G4 -G9) is provided for community floodplain managgmont purpasps. –G4- P'15RMITMBER— — G5�7AY ISSUED G7. This permit has been issued for: 1_1 New Construction 11 Substantial Improvemont 08. Elevation of as -built lowest boor (including basement) of the building is: _ ft.(rn)Datum: G9. 6FE or (in Zone AO) depth of Gooding at the building site is; _ _ 4-(M)Datum: ( tSCi� OFTITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENT Check here If attachments rc&AA r,,,-,,, A1_111 II II nn RFPI Ar -PA At I PRF%/Inl IA FnITIONC