2-4-020:039 - Laserfiche WebLink

Home

IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use: BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number 103 KUYu? ILT STK SET CITY HILO STATE HI 96720 ZIP Citompany NAIC Number 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 J 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 E3. If the Efevation Certificate is intended for use as supporting information for a LOMA or LOMR-F, Section C must be completed. E1. 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 J—J_J ft.(m) J_J_Jin.(cm) J—J above or J_J below (check one) the highest adjacent grade. 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? J_J Yes' J—J No J—J 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, B, and E for Zone A (without a FEMA -issued or community -issued BFE) or Zone AO must sign here. AMOPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE DATE TE4EPHONE COMMENTS 1_1 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 item(s) and sign below. G1. I,J 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. J—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. G3. J—J The following information (Items G4 -G9) is provided for community floodplain management purposes. ERMiT NUMBER I G5. DATE PERMIT ISS ISSUED G7. This permit has been issued for: J_J New Construction 1_1 Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m) Datum: G9. BFE or (in Zone AO) depp& ARg6tf b9JIdgi#1S istYorkS _ ft.(m) Datum: ��ginnerir��--�i��isien htas r�view LOCAL OFFICIALS NAME e�dTITLE the Elevation Certificate and 04T COMMS -11 recommends does not re TELEPHO VVL By n -s_ Ll io1 Dl z I 1 r hor!( horn if attarhm4-nf1