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soo;l.v4d: 9/30/04 14 ;341; Q122549Q61 .1. I:iUEEN INSURANCC A' NCY; PAQo 2
AUG.30'2004 14:21 9123553951 GA FARM BUREAU #5353 P.002/003
• . ELEVATION CERTIFICATE (
. Important: Reed the Instructions on papas 1 - y,
9ECTWTt l - PROPERTY OWNER INFORMATION 1 For Mpurence Company use:
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BUILOINO STREETAd13R (I ncluding Apt, UnM,tulle, snOrar Bldg. NO OR P.O. ROUTE AND 801(NO : Company NAIL Number
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CITY ....r.� -Grdhd�
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O1/RAHNL• 1.14 e. • • • e , ' . n... • • a ' l i t on, .. asory, e c. 1®e a ommen ; area, n noessol ty) ,�•••,,•'�
LA II 1 uue16Ui� II 1 ► tOPT1UNAL) HORIZONTAL OA WM; bUUHL : LI OI'S (fye),
( or *sow - rater or 911.1119* 10 LI NAO 1927 I J NAO 1983
LI uSts cams Map i_1 Other
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
eft. NRIF COMMUNITY NAME & COMMU ITV / `� 'IYIw1
R 192. COUNMNE I U3. STATU G4
04 M/V+ANL/ bF11vet !!�, SUtFUI kW. MIMI INUtJ1 tat, hIIIM PANk4 UU. 1 Hu. UASE FLOOD
NUMtieft EFFECTIvE Emi D 0 ATE Z0 1? (S {Zone Ageoth of flooding)
(4i6 4 ciao/ / C 6A /86_ 6//7 / O6 _ •
110. indicate the source of the se Flood Elevation (FIFE) data or base Hood depth :entered In B9.
LI PIS Profile LTF1RM I._I Community Cot ined L I Other (Describe)'
111. Indicate the elevation datum used for the BFE In B9: h GVO 1929 )_ I NAV D 1990 Li Other (Descrlbo)•
112, Is Iho building located in a Coastal Barrier Resources System (DORS) Aron or 0 hefwise Protected Are (OPA)7 1-,-,1 Yes I
Designation Dale:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
:1, Building - elevations are based on: I_IConstrucllon prawlnps I Construction' I Inlahed Conilruc ►Ion
•A new Elevation Certificate wilt be requfrod when construction elk, building is �amptelo.
:2. Building ',Ingram Number _j_ (Select the building diagram most similar W the aulidirtg for which (hie certificate is being completed • see
popes 0 and 7, It no diagram accurately represents the building, provide a 9ketcl or photograph.)
:3. Elevations - Zones Al -A30, AE, AM. A (with BFE), VE, Vi.V30, V (with 13FE), AR ARIA, AR /AE, AR /A14130. AR /AH, ARSAO
Complete Items C3,a -1 below according to the building diagram specified in Item t :2. Slate tho datum used, It the datum Is dirlerent from
the datum used for the EIFE in Section 8, convert the datum to that used for the 8 %E. Show field measurements and datum conversion
calculation, Ua*o tho specs provided or the Comments area of Section D or Sectl nt 0, no appropriate, to document the datum conversion
D atum .1 Conversion /Comments
Elevation reference Merk need Doso the elevation refer nce mark used appear on the FIRM? 1_1 Yee o
CI e) Top of bollonl Floor (including be element or enclosure) . t . f1,(lwt
ti b) Top of next higher floor J ! / , � �i
ft.(m) tl �(,� R ( `
0 c) 8oliom of IoweSf horizentaf structural member (V tones only) . i , Ct a
O d) Attached garage (lop of slab) ��
ft.(m) 7 O '9
0 a Lowest elevallon of mechtnery andlor equipment
servicing the building (Describe in a Comments area.) 67 , k_ ft,(,r,+� ti 1 4 No "�40 . 1
f 1 0 f) Lowoel adjacent (finished) grade (L11G) •,- 11 (le \ ir k � 4 . � �c /,
0 p) Highest adjacent (finished) grade (HAG) i � ,, /-� f1.(m7 , Un'I +
O h) No, of permanent openings (flood venla)wIthin 1 R. above adlr n1 prods, __VIA .1 � ' h /rl. EY p � D\ la
0 I) Toll area of all permanent openings (flood vents) In C3.h sq. in. _sq, cm) - -- ( b
SECTION D • SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This cartlficallon I6 lo be signed end sealed by o land surveyor, engineer, or inch Ile 1 authorized by law to certify elevation information,
1 cOrtIry thenformalionIn SedflonSA. B, and C on ihts certificate represents m bust efforts to Inferprof the date ovtttteele.
I understand (het eny lbise statement may be punishable by line Of imprrsonm u der 18 11. S. Code, Section 1001.
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Received: 0 /30 /04 14:3a: 0/23683961 -o. DUB XNSUR NCE . ;NCY: P•De 3
AUG.30'2004 14 :29 9123553951 GA FARM BUREAU *5353„P
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SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT (CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) InsurancelegenUoompeny. and (3) building owner,
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1' 1,..I Check horn It attachments
5LrCTION E - DUILDING ELEVATION INFORMATION (SURVEY NOT RECWRED) FOR ZONE AO AND ZONE A (WITHOUT E1
For zone AO end Zone A (without EWE), complete Items E1. through E4. If the Elev Lion Certificate Is intended for use n s omen°
Information for D LOMA or LOMR•F, Section C must be completed.
E1. Building Diagram Number (Select the building dlegram most similar to th building' for which elle certificate le being completed -
see pages fl and 7, If no diagram accurately repreecnte Iho building, provide a t ketch or photograph.)
E2. The top of the bottom floor (include') bseenlent er enclosure) of the building In 1_,1_1 R.(m) j_1_l n,(cm) I above or I_.I below
(check one) the highest adjt cent grade. (Use natural grade, if ennoble.)
E3. For Building Diagrams 0-0 with opening+, (see pegs 7). the next higher floor or et vested floor (elevation b) el the buildinp is
LL 1 i J.. 1in.(cm) above the highest adjacent grade. Complete Items , :3.h and C3 I on front of form.
E4. For Zone AO only. If no flood depth number is available, is the lop of the bottom Moor elevated In accordance with the cemmuney e
floodolaln management ordtnence9 j1 Yes I_( No 1 1 Unknown. TM toed ofnetol must certify this in(onneuon in Section G.
SECTION F - PROPERTY OWNER fOR OWNER'S REPRrES!MTATIYE) CERTfFICATtON
The property owner or owners authorized representative who completes Section, 4. a, C (Items C3,11 and C3.1 opy), and e for Zono A
(without a FEMA- Issued or community-issued (WE) or Zone AO mull sign hero, Th
r. stefemenIs in Sections A, S. C. end E ere correct 10
the blast of knowledge.
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nut1NCob LiIY ti'IAIL LIPC:litlh
a1 os IVr1C uw 1 h Ibj.t;NHUNt:
UUiNMbN I O
1 I Check her If attachments
SECTION G - COMMUNiTY INFORMATION (OPTIONAL)
The Iocel official who M authorized by law or ordinance to edminieter the community'6 floodpleln monogornont ordlhonce can complete
Sections A, 9. C (or E), and 0 of this Elevation Certificate. Complete the eppliceble tem(s) and sign below,
01. i .,.) The information in Section C was taken from other documentation that hoe t eon signed and emboeood by 0 llcunced surveyor,
engineer, or architect who is authorized by siOlto or local law to certify eleva ion Information. (indicate the source and dale 01 the
elevation data In the Comments area below.)
02 .1_1 A community etfleiet completed $eetlon E for a building located In Zone A ( ithout a FEMA locaed or community-issued t9FE) or
Zone AO.
GS. U Tho wow' ng lnformation ((tame G4.09) le provided for community eocdplol management purpose..
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07, Thls permit has been Issued lot: I_1 New Construction I_1 Substantial Ire rovemont
08, Elevation of ae.bullt lowest floor (Including basement) of the building 1e: fl,(m)Dolum;
G9. BFE or (in Zone AO) depth of flooding at the building elte le: ,_ 11.(m)Delum;
kV AL OF PIL.N. `V NAme HIM
COMMUNITY NAME TELEPHfINt
SItj4ATUHE DATE I
I;UMMEN I S
1 t Check horn if attachmentss
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