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IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Corppany_Usg: BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number CITY STATE ZIP Cq Company 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_J 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. E 1. 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 1J_1 ft.(m) 1_1—lin.(cm) 1_1 above or (_J below (check one) the highest adjacent grade. E3. For Zone AO only: If no flood depth number is availab pe 15. the top of the bottom floor, elevated in accordance with the community's floodplain management ordinance? 1_1 Yes 1_1 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. PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME AM ESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE 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. 31. 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.) 32. 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. 33. 1_1 The foilovvinglnformation (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBERI G5. DATE PERMIT ISSUED I G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISS ,7. This permit has been issued for: 1._1 New Construction 1!1 Substantial Improvement >8. Elevation of as -built lowest floor (including basement) of the building is: ft.(m) Datum: 19. BFE or (in Zone AO) dep%of fbodiwt the WIMP site is: r ft.(m) Datum: e ep ment of Piihl,� LOCAL OFFICIAL'S NAME Engineering Division has reviewed TITLE COMMUNITY NAMEetievation Certificate and TELEPHONE final approval Check here if attachments TAA Pnrm P1.11 niIn 00-'- -_