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Home My Public Portal AboutSecond Av_12 FcOr AL EMERGENCY MANAGEMENT Ar''Nr O.M.B. No 3067 -0077 .v, .. (ONAL FLOOD INSURANCE PROGI il Expires July 31, 2002 ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION I For Insurance Company Use: 1 BUILDING OWNER'S NAME 1 Policy Number BUILDI G ST E- ET ADDRESS (Including Apt,, Unit, Suite, and /or Bldg. No.) OR P.O. ROUTE AND BOX NO. i Company NAIC Number C ITY / g L!M`1'P 5 T.M. Z1Pg / ; aI°S PROPERT D S1 N (2 ' Blocl { - 6Ts, Ta4I -- -A. e4, Le�lDes etc.) BUILDING U sidential, Non - residential, Addition, Access6ry, etc. Use Comments section if necessary.) / (e-� " LATITUDE /LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: 11 GPS (Type): ( ##° - ##' - ##•##" or #4.##W#°) 1,1 NAD 1927 L. NAD 1983 L1 USGS Quad Map 1 1 Other: SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 7.v/12. NFI COMMUNITY NAME & COMMUNITY ) 4- B 2. COUNTY 7 6A STATE A - B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL B8. FLOOD B9. BASE FLOOD ELEVATION(S) N UMBER pATE EFFECTIVE/RyVISED/ DATE ZOAIE(S) (Zone A0, use depth of flooding) 1 �16 acd G / 1 /�6 6 / / 7 /86 n tS 4- B10. Indicate the source of the ase Flood Elevation (BFE) data or base flood depth entered in B9. 11 FIS Profile 1 FIRM 1_1 Community Determined 1 - 1 Other (Describe): B11. Indicate the elevation datum used for the BFE in.B9: L NGVD 1929 1 1 NAVD 1988 1,1 Other (Describe): BI2. Is the building located in a Coastal_ Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 1 i Yes i Designation Date: SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) / C1. Building elevations are based on: 1_IConstruction Drawings* 1 1Building Under Construction* 1/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 C3a -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 /UC7OP Z ' Conversion /Comments Elevation reference mark used Does the elevation reference tri used appear on the FIRM? 1_1 Yes I <No ❑ a) Top of bottom floor (including basement or enclosure) - '7 C} i ft.(m) ❑ b) Top of next higher floor fi .P ;ft.(m) ❑ c) Bottom of lowest horizontal structural member (V zones only) ft.(m) 2 0 ®��p`` ❑ d) Attached garage (top of slab) ` ft-(m) t 2 - ` OTERF ,0 " ' ` ❑ e) Lowest elevation of machinery and /or equipment u, Q� servicing the building / . 5 ft.(m) , ' ❑ f) Lowest adjacent grade (LAG) 1 4 j ft.(m) z g ❑ g) Highest adjacent grade (HAG) 1 .3ft.(m) 8 I:21 h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade 0!� • ❑ 1) Total area of all permanent openings (flood vents) in C3h v sq. in. (sq. cm) ' SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION • This certification is to be signed and sealed by a and surveyor, engineer, or architect authorized by law to certify elevation infomiation. 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. CERTiFIE S1y11/ 7-J j� &V tv LICENSE U%R ,� TITLE t , COMPANY NAME ADDRF6S 2 , / o Cl p f 2 4 17 ow z 1P i t g . / -- SIGNA2i;E j /7" - DATE /d/ TELEPHONE �� _ 46 FEMA F 81 -31, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS IMPORTANT: In these spaces, cop F rresponding information from Section . I For Insurance Company Use: BUILDIN9 STREET .B,DRESS (Including r,pt �ui and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. I Policy Number CITY �i,Q 1 r) � rompany NAIC Number SECfiION 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 LI 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 LLI ft.(m) LL_lin.(cm) Ll above or I 1 below (check one) the highest adjacent grade. E3. For Building Diagrams 6 -8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is II ft.(m) l _ I — lin.(cm) above the highest adjacent grade. 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? I_I Yes II No II 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, and E for Zone A (without a FEMA- issued or community- issued BFE) or Zone AO must sign here. • PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE COMMENTS LI 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. I 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 I A community official completed Section E for a building located in Zone A (without a FEMA- issued or community- issued BFE) or Zone AO. G3. II 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: ` ft.(m) Datum: LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS Check here if attachments FEMA Form 81 -31, AUG 99 REPLACES ALL PREVIOUS EDITIONS