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Home My Public Portal AboutButler Av_1309 ■ FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067 -0077 \, TIONAL FLOOD INSURANCE PROGRP Expires July 31, 2002 d2. ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION I For Insurance Company Use: BUILDIN,(3 OWNER'S NAME ,-, Number Lf/T/(/ /. Z91/f 2X/c. BUILDING STREET ADD S (Including Apt, Unitsuite, and /or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number 7° 74//f-- CITY /O� l L.... STAB ZIP O0 E PROPER DESCRIPTION (Lot and B do u rs Tax Parcel Nu ber, Legal Description, etc.) 1- N 077 . `_ t.: --- . 8UiLUiNV tg,Caentiai, ivon -r siden al, Addition, Accessory, etc. use a comments area, if necessary.) LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCL LJ GPS (Type): . ( /AV -444e - ##:#lf or ##./ttstAV) Lj NAD 1927 LI NAD 1983 L USGS Quad Map L Other. SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 81. NFIP COMMU - Y NAME & COMMUf�il]t;Nl�, A ER, B2. COUNTY NAM I B3. STATE GA, 2.4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL ti8. BLOOD B9. BASE FLOOD ELEVATION(S) NUMBER pAT EFFECTIVV/ R ED DATE Z E( (Zone AO, use depth of flooding) /5g7K t o�z C X117 6/I7 / 5 /2 810. Indicate the source of the ase Flood Elevation (BFE) data or base flood depth entered in B9. I1 FIS Profile I_LiFIRM II Community Dete fined II Other (Describe): 811. Indicate the elevation datum used for the BFE in B9: I_ ....raGVD 1929 II NAVD 1988 I'Other (Describe): B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I_I Yes I---(No Designation Date: SECTION C - BUILDING ELEVATION INFORyATION (SURVEY REQUIRED) 01. Building elevations are based on: I _'Construction 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 02. State the datum used. If the datum is different from the datum used for the BFE in Section 8, 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 Uk 2;1 Conversion /Comments Elevation reference mark used Does the elevation reference mark used appear on the FIRM? I 1 Yes 1-o1'No Q a) Top of bottom floor (including basement or enclosure) /2 . ft.(lfirj v ____ ❑ b) Top of next higher floor _ ft.(m) u' / R ❑ c) Bottom of lowest horizontal structural member (V zones only) 0 f,4 , . _ ft.(m) a o f , . TF �� ` , I:1 d) Attached, garage (top of slab) /1 (, ft.( r) e / �' F t I:2 e) Lowestelevation of machinery and /or equipment W Q � servicing the building (Describe in a Comments area.) ft.(m) E ( 7 ' No. 49 ❑ f) Lowest adjacent (finished) grade (LAG) /D . ft.( r} z i y c r CO CI Highest adjacent (finished) grade (HAG) ./ I . / ft.( } �' - >, O " p / ` • Ca h) No. of permanent openings (flood. vents) within 1 ft. above d"a nt grade G, � f SUR� Q � y�' U i) Total area.of all permanent openings (floodvents) in C3.h sq. in. (sq...cin) TL l 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 LICENSE NUMBER TITLE COMPANY NAME ADDRESS, / c. 'L %, Cifc g/ ST Ee ZIP CODy/�� SIGNATl1R�z! , / DATE / /`b / TELEPHONE .57---2 - o4/ / - PPU Rnrm 1 .1111 nn - CPP RR1 /FRCP Clr)R R(IR r r1NTINl IATIr1N RRPI AC PS Al 1 PRR1l1(1I I.0 Fr117Ir1AIC• P copy from I For Insurance Company Use: IMPO GAS T:E1�( spaces, cop the corresponding Q information fom Section A Bldg, No.) ._.d .. .. Policy BUILDI RE ndudi r. u, 9 _ ST j mo OR P.O. ROU ► � AND BOX �' E C.om ari NAIL Number -,5► �, p Y SECTION 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 —. 1I 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 E1. 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 1_1,1 ft.(m) 1 1_1 above or 1I 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 or elevated floor (elevation b) of the building is I_j_j ft.(m)1_Ilin.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form. 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 1 Yes I I No 1.1 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, 8, C (Items C3.h and C3.i only), and E for Zone A (without 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 the best of my knowledge. PROPERTY OWNER'S OR OWNERS AUTHORIZED REt'RESEN MINES 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, 8, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. G1.1 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. 1 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. I_1 The following information (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER G5. DATE PERrvi T ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7. This permit has been issued for: 1 New Construction 1I 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 OFFICIALS NAME - TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENT "S J I Check here if attachments PFMA Fnrm S=11-11 .1111 nn PRP( ACS Alt PP VICII IC.FrlIT1CThL