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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 CITY STATE ZIP Cd Company NAIC Number dh 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. 1-1 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 Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F, Section C must be completed. Ef. 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_jJ ft.(m) LJJ1n.(cm) L above or LJ 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? JJ Yes' JJ 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. B. and E for Zone A (without a FEMA -issued or community -issued BFE) or Zone AO must sign here. S SIGNATURE DATE TELEPHONE COMMENTS jJ 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. L_l 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- nformatien (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBEfl G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7. This permit has been issued for. 1_1 New Construction [—I 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 buildinsite is: _ ft.(m) Datum: . Th Department �j Pe is: lhforks LOCAL OFFICIAL'S NAME Engineering Division has reviewed COMMUNITY NAME the Elevation Certificate and TELEPHONE DA GV�YIIYI GIV 1 J final approval Check here if attachments