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mL 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 -7M k- 1-4 -- b 11 : D 2-n CITY STATE CODE 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 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 E5. If the Elevation 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 1_I-1 ft. (m)1-1-1 in. (cm) 1-1 above or 1-1 below (check one) the highest adjacent grade. (Use natural grade, if available.) E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is —I—I ft. (m) 1_I—lin. (cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form. E4. The top of the platform of machinery and/or equipment servicing the building is 1_1_1 ft. (m)1-1-1 in. (cm) 1_1 above or 1_1 below (check one) the highest adjacent grade. (Use natural grade, if available.) E5. 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? 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, C (Items C3.h and C3.i only), and. E for Zone A (without a FEMA -issued or community -issued BFE) or Zone AO must sign here. The statements in Sections A, B, C, and E are correct to the best of my knowledge. gh PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS 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. G1. 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.) 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 information (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER G5. DATE PERMIT ISSUED I ISSUEDATE CERTIFICATE OF COMPLIANCE/OCCUPANCY I G7. This permit has been issued for: 1_1 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) dl;hi!� d$i pdktg*tihedfji1ftbOde Works _ ft. (m) Datum: �nninor.+rinn CiiviS'4i11-�1C�S r@V!@V1%@d LOCAL OFFICIAL'S NAME the Elevation Certificate and TITLE COMMUNITY NAME ® recommends TELEPHONE SIGNATURE idoes not recommenid DATE NTS Date 3` 1 �O 1_1 Check here if attachments FEMA Form 81-31, January 2003 Replaces all previous editions