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IMPORTANT: In these spaces, copy the corresponding information from Section A. j For Insurance Company Use, BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number STATE 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 I _ I 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 E5. 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. It 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_I_I ft• (m) 1_L-1 in. (cm) L1 above or I_I 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 LI_I fL (rn) LL—lin. (cm) above the highest adjacent grade. Complete Items C3.h and C3.1 on front of form. E4. The top of the platform of machinery andlor equipment servicing the building is I_I_I ft. (n)1 _1_1 in. (cm) L1 above or I_1 below (check one) the highest adjacent grade. (Use natural grade, If available.) E5. 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 n _..d�i..:� �.................. ....rinnnrne I I Vne I I Mn I I I fn4nnu,n Tho Inrel nffiri Al must rAAitu thio InfnrmAtinn In 3Artinn ra. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A, B. C (Items C3.h and C3.1 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 OWNER'S AUTHORIZED REPRESENTATIVE'S NAME DRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE .KHu1,5l�ili-� 11 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 hem(s) and sign below. G1. 1_1 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_1 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. 1_1 The following information (Items G4 -G9) is provided for community floodplain management purposes. G5. DATE PERMIT ISSUED G7. This permit has been G8. Elevation of as -built I G9. BFE or (in Zone AO) Is: ISSUED LOCAL OFFICIAL'S NAME ° rdIUt1 el'IllGafe and TITLE COMMUNITY NAME- TELEPHONE does not recommend SIGNATURE final approval DATE _ ft. (m) Datum: —ft. (m) Datum: r E GIEV, i•Z , i 0 w4[rc i{� RZL"72 T uE; c� f�tt ,E MA Form 81.31, January 2003 Replaces all previous