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co.., E` �: A�°TI N CERTIFICATE
I mportant: Read the instructions on pages 1 - 7.
SECTION A - PROPERTY OWNER INFORMATION I For Insurance Company Use:
ILDING ER'S NAME I Policy Number
, ��.f
1LDlN��� ADDRESS (Incfudinq Apt., Una, Sind /or Bldg..) OR P O. ROUTE AND BOX NO. I Company NA1C Number
OPERTY D - SCRIPTION (l Blo To P rcal Nu b r a
ILDING u g_.• asidenfiaYNon- residential, Addition, Accessory, etc. Use a fiomfients area if necessary.) •�V !�
TITUDE LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: U GPS (Type): • § "°`- - v_, — r»
#°- ;I#' - ##.114r or ##.i # °) Lf NAD 1927 I_ j NAD 1983 Lf USGS Quad Map Li Other.
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
� NFi UN t 7- j E , & COMMI�N �ER 182. COUNTY E 183. STATE
34. MAP AND PANEL 85. SUFFIX B6. FIRM INDEX B7. FIRM PANEL 88. FLOOD 69. BASE FLOOD ELEVATION(S)
R
NUMB pATE EFFECTIVE/ EVIS DATE ZON S) AO, use d th of flooding)
5' 64 l e 6%/7 AK 6//7/ h J48 (Zone AO
Indicate the source of th se Flood Elevation (13FE) data or base flood depth entered in B9.
J F1S Profile izj FIRM 1I Community De fined LI Other(Describe):
. Indicate the elevation datum used for the BFE in B9:1/1 NGVD 1929 1_1 NAVD 1988 j_1 Other (Describe):
Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? iJ Yes Li No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMION (SURVEY REQUIRED)
Building elevations are based on: 1 'Construction Drawings' 1 /1Building Under Construction* j_lFinished Construction
'A new Elevation Certificate will be required when construction of the building is complete.
Building Diagram Number -7 (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.)
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 ace provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
Datum
Ajax Conversion /Comments
Elevation reference ark used Does the elevation reference mark used appear on the FIRM'? jJ Yes j Flo
❑ a) Top of bottom floor (including basement or enclosure) /4 Q ft.(nt)-
❑ b) Top of next higher floor . -j ft.(FF
❑ c) Bottom of lowest horizontal structural member (V zones only) . ft.(m) o o ��
I:1 d) Attached garage (top of slab) / Z - _ ft. 3- E >S I E >
0 A
❑ e) Lowest elevation of machinery and /or equipment ` ` W
servicing the building (Describe in a Comments area.) _ ft.(m) E * No. 2249
❑ f) Lowest adjacent (finished) grade (LAG) /7. 0 ft.(m) z' i t y t , o
❑ g) Highest adjacent (finished) grade (HAG) !7 ft.(m) v , SUR`I �
❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade _ ;- , / �\
CI i) Total area of all permanent openings (flood vents) in C3.h sq. in. (sq. cm) /71 El 0
SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
pis certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
- ertify that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available,
nderstand that any false .statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
RE M COMPANY NAME FIER'S NAME/ Ro LICENSE NUMBER 3z�a
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.DRESS �` '1' A ir / 41 l / CITY �� ST // ZIP CODE 4i
GNATUFtE /// / > J / r QTE 4, TELEPHH ����Q �,
All F'nr R1 -'�1 I C* SFF PRV RSP R1f1 FIIP r.nnfriNi IATIr1N PRPI Ar:FC Al I PPP \ /I(li IS PIIITInnis
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