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O.M.B. NO. 3067.0077 C 0 Py ELEVATION CERTIFICATE Expires May 31, 1996 FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM *TTENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to rovide elevation information necessary to ensure compliance with applicable community floodplain management ordinances, to determine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Revision (LOMA or LOMR). Instructions for completing this form can be found on the following pages. SECTION A PROPERTY INFORMATION I FOR INSURANCE COMPANY USE BUILDING OWNER'S NAME POLICY NUMBER STREET ADDRESS (Including Apt., Unit, Suite and/or Bldg. Number OR P.O. ROUTE AND BOX NUMBER I COMPANY NAIL NUMBER t36o 1-•OA t lc MA,' O Number) OTHER DESCRIPTION (Lot and Block Numbers, etc.) LoT t s KA10A1LhQ1 C-a1ZriYT_- CITY`O STATE `, 1 ZIP CODE SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION Provide the following from the proper FIRM (See Instructions): 1. COMMUNITY NUMBER 2. PANEL NUMBER 3. SUFFIX 4. DATE OF FIRM INDEX 5. FIRM ZONE 6. BASE FLOOD ELEVATION Cj rj b $ lin Aosl�asuse depth) 1 7. Indicate the elevation datum system used on the FIRM for Base Flood Elevations (BFE): '0 NGVD'29 ❑ Other (describe on back) 8. For Zones A or V, where no BFE is provided on the FIRM, and the community has established a BFE for this building site, indicate the community's BFE: I I I I I I IJ feet NGVD (or other FIRM datum=see Section B, Item 7), SECTION C BUILDING ELEVATION INFORMATION 1. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best describes the subject building's reference level _I . 2(a). FIRM Zones Al -A30, AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an elevation of 119,11;IS .6 feet NGVD (or other FIRM datum—see Section B, Item 7). (b). FIRM Zones VI 430, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level from the selected diagram, is at an elevation of I I I I I I .0 feet NGVD (or other FIRM datum—see Section B, Item 7). (c). FIRM Zone A (without BFE). The floor used as the reference level from the selected diagram is W .0 feet above ❑ or below ❑ (check one) the highest grade adjacent to the building. (d). FIRM Zone AO. The floor used as the reference level from the selected diagram is W .0 feet above ❑ or below ❑ (check one) the highest grade adjacent to the building. If no flood depth number is available, is the building's lowest floor (reference level) elevated in accordance with the community's floodplain management ordinance? ❑ rYeets El No ❑ Unknown 3. Indicate the elevation datum system used in determining the above reference level elevations: u NGVD '29 ❑ Other (describe under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is different than that used on the FIRM [see Section B, Item 7], then convert the elevations to the datum system used on the FIRM and show the conversion equation under Comments on Page 2.) 4. Elevation reference mark used appears on FLJ ❑ Yes ® No (See Instructions on Page 4) 5. The reference level elevation is based on: actual construction ❑ construction drawings (NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which case this certificate will only be valid for the building during the course of construction. A post -construction Elevation Certificate will be required once construction is complete.) 6. The elevation of the lowest grade immediately adjacent to the building is: I l 414161.& .feet NGVD (or other FIRM datum -see Section B, Item 7). SECTION D COMMUNITY INFORMATION 01. If the community official responsible for verifying building elevations specifies that the reference level indicated in Section C, Item 1 is not the "lowest floor" as defined in the community's floodplain management ordinance, the elevation of the building's "lowest - floor" as defined by the ordinance is: I I I I I I .LJ feet NGVD (or other FIRM datum—see Section B, Item 7). 2. Date of the start of construction or substantial improvement FFMA Form 81-31, MAY 93 REPLACES ALL PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION