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IMPORTANT: In these spaces, copy the corresponding information from Section A. ' For Insurance Company <br />BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX N0. I Policy Number <br />CITY <br />STATE <br />ZIP Cq Company NAIC Number <br />0 SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) <br />Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner. <br />COMMENTS <br />Check here if attachments <br />SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and ZONE A (WITHOUT BFE) <br />For Zone AO and Zone A (without BFE), complete Items E1 through E3. If the Elevation Certificate is intended for use as supporting <br />infomration for a LOMA or LOMB -F, Section C must be completed. <br />E1. Building Diagram Number (Select the building diagram most similar to the building for which this certificate is being completed — <br />see pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) <br />E2. The top of the bottom floor (including basement or enclosure) of the building is JJJ ft.(m) UJin.(cm) )J above or (J below <br />(check one) the highest adjacent grade. <br />E3. For Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the commundy's <br />floodplain management ordinance? iJ Yes' 1_1 No 1_1 Unknown. The local official must certify this information in Section G. <br />SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION <br />The property owner or owner's authorized representative who completes. Sections A, B, and E for Zone A (without a FEMA -issued or <br />community -issued BFE) or Zone AO must sign here. <br />PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME <br />4WFDRESS CITY STATE ZIP CODE <br />SIGNATURE DATE TELEPHONE <br />COMMENTS <br />1_1 Check here if attachments <br />SECTION G - COMMUNITY INFORMATION (OPTIONAL) <br />The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete <br />Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. <br />G1. I_I The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, <br />engineer, or architect who is authorized by state or local law to certify elevation information. (Indicate the source and date of the <br />elevation data in the Comments area below.) <br />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 <br />Zone AO. <br />G3. 1_1 The following information (Items G4 -G9) is provided for community floodplain management purposes. <br />G4. PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY <br />ISSUED <br />G7. This permit has been issued for: 1_1 New Construction 1_1 Substantial Improvement <br />G8. Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m) Datum: <br />G9. BFE or (in Zone AO) depth of flooding at the building site is: _ ft.(m) Datum: <br />LOCAL OFFICIAL'S NAME The Departmen R$ TITLE <br />Engineering Di -i ion hrn, reviewed <br />COMMUNITY NAME the Elevation Certificate anTELEPHONE <br />i( <br />NATURE recommends DATE <br />r <br />v4WMMENTS " <br />L] Check here if attachments <br />P_P:hAA Gnrm R4_11 AI I(_ CIC] Doto • • •-- - - <br />