HomeMy WebLinkAboutELEVATION CERTIFICATEKI
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II . FEDERAL EMERGENCY MANAGEME'NTMCENCY O.M.B. No. 3osr-Oorr
l„ s R I 2001 NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002
_ - ELEVATION CERTIFICATE
St I r Importaft, Read the instmetions on pages 1- 7.
SECTION A - PROPERTY OWNER INFORMATION For Insurance Carmarry use:
BUILDING OWNER'S NAME
Lr
A , F £ t
P L a ,� ... .
BUILDING STREET ADDRESS onduding ApL, Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number.............-:
10Z2S S•o C-Iz10,VV 14 LoT 2(
my, 11,
STATE ZJP CODE
PROPERTY DESCRIWTION (Lot and Bloa Numbers, Parcal Number, Leal Description, etc.)
L6T 7, Loc K 1, ' oI In d v I`�. fT
Addition, Acoessiory, etc. Use
if necessary
Its' -I - N �WRIAL+M:
SOURCE: I GPS (Typ):
NAD NA1N3�7i
USGS Quad Map L-i Other
III 5ECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
NFIP'ICIOMMUNITY�AM E & COMMUNITY NUMBER 82 COUNTY NAME B3,
JAJtZI o>21� / 12D z_ss Lu
12.0Zf
B10. Indic;
I-1F
B11. Indiu
B12. Is the
C1. Buildirq
'A new
C2. Building
pages (
C3. Elevatio
Comple
Me datu
calculab
Datum _
Elevabo
O a) Tq
O b) Tq
O c) Bol
O d) AM
O e) Loy
ser
O 0 Low
O g) Higl
O h) No.
O i) Total
This ce' rtificab
I cerafy that B
I undeistand t
oo. rLwu !Ill. tiAI FLOOD ELEVATION(S)
DATE �� EFFE ( IS DATE ZONE(S)
(Zone AO, use of flooding)
S- v313 t='
e the source of 014UM Flood Eleva (BFE) data or base food depth entered In B9.
S Profile FIRM u Comrtuurity L-1 Other (Describe):
e the elevation datum used for the BFE in 89: NGVD 1929 LI NAVD 1988 L-1 Other (Describe):
wilding located in a Coastal Barter Resoumes System (CSRS) area or Otherwise Protected Area (OPA)? 1_1 Yes. o
lesion Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
elevations are based on: I_IConWuc ion Drawings® LkPullding Under Construction' 1—IFinished Construction
=levation Certificate will be required when crosMxdm of the building is complete.
Diagram Number 61_ (Select the building diagram most similar to the building for which this certificate is being completed - see
and 7. If no diagram accurately represents the building, provide a sketch or photograph.)
s —Zones Al-A30, AE, AH, A (with SFE), VE, V1430, V (with BFE), AR, ARIA, AR/AE, AR/A1 A30, AR/AH, AR/AO
Items C3a4 below according to the building diagram specMed'(n Item C2. State the datum used. If the datum is different from
Ir used for the BFE In Section B, convert the datum to that used for the BFE Show field measurements and datum conversion
n. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
Conversion/Comments
referertoe mark used Does the elevation reference mark used appear on the FIRM? Ll Yes o
of bottom floor (in u ft basement or enclosure) / 3 •� ft,(m) if
Of next higher floor' _ fL(m) y
)m of lowest horizontal structural member (V zones only)
*W garage (top of slab) _ R(m) E g
Est elevation of machinery and/or equipment w
icing the !wilding _ R(m) z -
st adjacent grade (LAG) y •� R(m) .2k
69 adjacent grade (HAG) '-I (o R(m) -
perrianent openings (flood vents) within 1 R above adjacent grade
Tree of all permment openings (flood vents) in C3h sq. In. (sq. «„)
xI, I rum U - UUKVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
I Is to see wgneo aria S681M by a land survI engineer, or architect authorized by law to Certify elevation information.
/rrlbrmalton in SecLlons A, 8, and C on this cerdlrcate represents my best e!ibrfs to interpret the data available.
I any false statement may be punishable by fine or imprisonment under 18 U. S. Code Section 1001
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FESSI0NAL
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CFF I?FI/FRCP CIf1F
rr)NTINI IATIr1N
P;:PI Ar`PIZ al I DDnnru ac Gr%rri 1u;
IMPORTANT: In these spaces.
CITY
1 y, ✓•.i
the corresponding Information from S-cU A. For
"L. Unit, SUpA, ancUor BWg. No.) OR P.O. ROUTE AND BOX NO. 'Palk
a Company Uie: •,
or x
LP CODE FC—OMP&nY NAIC Number;
SECTION D - SURVEYOR ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insuran-ce agentloompany, and (3) building owner.
COMMENTS
•III= � ••
I 1 Check here If attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and ZONE A (WITHOU
T BEE)
For Zone AO and Zone A (without SFE), complete Items El through E3. If the Bevatlon Ce4ficate is intended for use as suppo►ti09
iNbrmWon for a LOMA arLOMRA Secdon C must be completed. -
E1. Building Diagram Number (Select the building diagram most similar to the building for which this certikAte is being completed —
see pages 6 and 7. If no diagram accurately represents die building, provide a sketch or photograph.)
EZ The top of ths,bottom floor (inducting basement or enclosure) of the building is I -I -I fl.(m) I—I—Iin.(cm) I-1 above or l-1 below
(check one) the highest ad)ecent graft. .
E3. 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? Yes No Unknown. The local official must certify this iMomration in Section G.
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION '
who completes Sections A, B, and E for Zone A (without a FEMA4ssued br
The property owner or owner's authorized representative _
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
if
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 items) and sign below. . .
G1. Lj The irrforrrlation in Section C was taken from other documentation that has been signed and:embossed by a licensed surveyor.
engineer, -.or atchiteG who is authorized by state or local law to certify elevation information. (Indicate the source and date of the
elevation daiar in the, Comments area below.)
G21_1 A community ofpal.completed Section E for a building located in Zone A (without a FEMA4ssued or community4ssued BFE) or
Zone ACC. �r,
G3.1..-1 The fallowing inft;hatio.� (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 hag,beah issued for. 1-1 New Construction 1-1 Substantial Improvement
GIL Elevation of a6;built,ld�west floor (including basement) of the building is: __ • — fL(m) Datum:
(m) Datum:
G9. SFE or (in Zons AO) depth of flooding at the building site is:
Rl l
1._I Check here if attachments
4
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