HomeMy Public PortalAboutPolk St_102 "' I Expires July 31, 2002
__`EVATION CERTIFICATE
Important: Read the instructions on pages 1 - 7.
SECTION A - PROPERTY OWNER INFORMATION I For Insurance Company Use:
BUILDING WNER'S NAME I Policy Number
o T 9 PS/i� lG S
BUILDING STREET AD i ESS (Includi Apt. Unit, Suite, and /or Bldg. No.) OR P.O. ROUTE AND BOX NO. ` Company NAIC Number
/0 f _ / I
CITY —T_ , _L. 4JIL3 3/5"
PROPER,TY DESCRIPTION (Lot iock Numbe , lax Paycel Number, Le 1 Descri r� �ch. ,� /
BUILDING,Li,SCe Retidential, Non- residential, Addition, Accessory, etc. se Comments area, if necessary.)
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: I__I GPS (Type):
( #4t - #i#' -11#.#4t" or 4#.##4/44 °) I I NAD 1927 IJ NAD 1983 I — I USGS Quad Map i_I Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMU NAME & C NUMB B2. COUNTY NAME 83. STATE
C ry / Ci A .
B4. MAP AND PANEL B5. SUFFIX 86. FIRM INDEX 87. FIRM PANEL B8. FLOOD I B9. BASE FLOOD ELEVATION(S)
NUM R AT EFFECTI /R VISED DATE ZO E(S (Zone AO, use depth of flooding)
B10. Indicate the source of the se Flood Elevation (BFE) data or base flood depth entered in B9.
II FIS Profile i FIRM I_I Community Determined I I Other (Describe):
811. Indicate the elevation datum used for the BFE in B9: I - 11�GVD 1929 II NAVD 1988 I_I Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? Li Yes I Vo
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
01. Building elevations are based on: I_IConstruction Drawings* I_IBuilding Under Construction* I'<Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. 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.)
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
calculation. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
Datum A/61/9 2 L Conversion /Comments -
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? I I Yes I-
❑ a) Top of bottom floor (including basement or enclosure) 7 .7 ft.(r;
❑ b) Top of next higher floor / 7 . Aft.(-Ft- a o R -
❑ c) Bottom of lowest horizontal structural member (V zones only) idly: ft.(m) N 1 v/ '`\
❑ d) Attached garage (top of slab) 7 .1 ft (, E II 0 „�� T Eq,^ '9 \
1=1 e) Lowest elevation of machinery and /or equipment w
servicing the building (Describe in a Comments area.) 1 L , ( ft. t; s. I _ No. 22.9 *
'2 E
❑ f) Lowest adjacent (finished) grade (LAG) <7 . f ft. (m) z m y Q- C
`
❑ g) Highest adjacent (finished) grade (HAG) . O. ft rn) l 11 . e , 16
❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade y! j sUR`I & / ❑ i P P 9 ( ermanent enin s Total area of all o flood vents ) � in C3.h s s �m ti ' LE' �`� � '
sq. in. (sq. ) �/
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, 8, 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 fe /. LICENSE NUMBER � G - .�
TITLE - COMPANY NAME '
ADDRESS C/ii , ✓adekr, /L. a , CI `i v, }� Zi / D�
SIGNATU 7 V BE ! T ` EELLEPHONE -
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