The URL can be used to link to this page

Home My Public Portal AboutSecond Av_1210 ELFVATION CERTIFICATE 1 Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION ( For Insurance Company Use: i LDING ARS, NAME , q A , i Policy iVumr�er I ILDING STREET ADDRESS (15,c.kuding Apt, Unit, Suite, nd /or Bldg. No.) OR P.O. ROUTE AND BOX NO. 1 Company NAIC Number Y _L__ J , n STATE 4 ZIP C Q ;Z(9 OPERTY D F,SCRIP ION (Lot aind Blodc N rrss, T Par I Number, Legal Description, etc.) ILDING U .g., Residential, Non- residenti/Addition, Accessory, etc. Use a Comments area, if necessary.) - ITUDE/LONGITUDE(OPTIONAL) HGRIGUN JAL UAI UM: SOURCE: I VPS (Type): ' ° - ##' - ##.##" or ##.#####°) Li NAD 1927 U NAD 1983 1_1 USGS Quad Map Li Other. SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION NFIP COMMUNIT E & COMMUNITY N MBE ' LiL. (;UUN I Y NAME 83. STATE ^ V,,1 —4 � , / Cl �' /,4- M (74 4. MAP AND PANEL 65. SUF-}-1X db. R-IRM IN0EX Ij/. hIKM PANEL 88. 1=L000 69. BASE FLOOD ELEVATIONS) NUMBER TE EFFECTIVE/R SE DATE ZON (S (Zone AO, use depth of flooding) c s/64 Z c �� /g6 � � �� iZ. Indicate the source of the se Flood Elevation (BFE) data or base flood depth entered in 89. I_J HS Profile I (...rrIRM Ij Community Dete fined j Other (Describe): Indicate the elevation datum used for the BFE in B9: 1 NGVD 1929 1j NAVD 1988 I Other (Describe): . Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I J Yes I Designation Date: ' SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) 3uilding elevations are based on: l Drawings' J!Building Under Construction' L vffinished Construction 'A new Elevation Certificate will e required when construction of the building is complete. 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.) Elevations - Zones A1 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 MVO 07Conversion /Comments levati L on reference mark used Does the elevation reference mark used appear on the FIRM? � Yes J -- l� O • a) Top of bottom floor (including basement or enclosure) / 1_ ft. • b) Top of next higher floor _ ft.(m) _ Q c) Bottom of lowest horizontal structural member (V zones only) t(A,, • — ft.(m) y W G o � ` d) Attached garage (top of slab) _ft.(m) E -2 / �G' 1\ e) Lowest elevation of machinery and /or equipment w m , servicing the building (Describe in a Comments area.) / Z . 9 ft.(. )- E ' ^ • 2^ 9 ❑ f) Lowest adjacent (finished) grade (LAG) Q . ft.(m -- z ..g ` y f - 0 ❑ g) Highest adjacent (finished) grade (HAG) P . ft.(m) 4. - , . uR�‹ =_ (� O h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade _ y O i) Total area of all permanent openings (flood vents) in C3.h sq. in. (sq. cm) �TL EY SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION / ,s certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. 9rtiry that the information in Sections A, 8, and C on this certificate represents my best efforts to interpret the data available. - Iderstand that any false statement may be pu ishable by fine or imprisonment under 18 U.S. Code, Section 1001. RTIFIER'S NAME/ // LICENSE NUMBER z� j�a - LE COMPANY NAME [[ GG ''�� DRESS / 6 1 � /,� CITY � / STA � ZIP CODE�� may „ � C� a...0 ��i `7C f`Fy �y ,�1 C Lf (J : NATURE ,,,/,,,,,,/ _ � DAT ... _...... .. ......... ... _/ fie 7 � Z " 4 /4 ... , - TELEPHONE �j Q L. Pnrm f2 1 nn SR PP \JRPS= .. lfP RnR r.fNTINI 1AT1ClN RPPI Ar`GR AI 1 PPP \ /ICII IS PMIT1ClNC ILDIN j��DDRE ding Apt., Unit 0e, or Bldg. No.) OR P.O. ROUTE AND BOX NO. I Policy Number YA � +� ST E I Company NAIL Number PLC SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) ;py both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner. )MMEN II Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) Zone AO and Zone A (without BFE), complete Items El. through E4. If the Elevation Certificate is intended for use as supporting )rmation for a LOMA or LOMR -F, Section C must be completed. 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.) The top of the bottom floor (including basement or enclosure) of the building is III ft.(m) I_I_lin.(cm) I above or I ^ J below (check one) the highest adjacent grade. (Use natural grade, if available.) For Building Diagrams 6 -8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is J_J_J ft.(m) l_J _lin.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form. 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 I , I No I I Unknown. The local official must certify this information in Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION )e 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 ithout 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 best of my knowledge. ?OPERTY OWNER'S OR OWNER'S AU I HO- JLEU NEPRESEN Al T IVE'S NAME )DRESS CI I Y S IAI t LIP CODE NATURE UA1 IELEPHONt DMMENTS lJ Check here if attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete lions A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. I 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 or elevation data in the Comments area below.) _J A community official completed Section E for a building located in Zone A (without a FEMA- issued or community- issued BFE) or Zone AO. I_J The following information (Items G4 -G9) is provided for community floodplain management purposes. 1. PERMIT NUMBER G5. DATE PERM! f ISSUED G6. DATE CER11FICA Ob COMPLIANCE/OCCUPANCY ISSUED This permit has been issued for: II New Construction II Substantial Improvement Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m)Datum: BFE or (in Zone AO) depth of flooding at the building site is: — ft.(m) Datum: • ,CAL OFFICIAL'S NAME 11 1 LE )MMUNITY NAME TELEPHONE • GNATURE DATE DMMENTS I i Check here if attachments %AG Rnrm A1_21 1111 nn P PI tt('F.s AI 1 PPR \ /I(>I IS PfITIfM