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IMPORTANT: In these spaces, copy the corresponding information from Section A. 1 For Insurance Company Use: <br />BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. I Policy Number j <br />CITY <br />— O tot ; <br />STATE <br />ZIP CQ Company NAIC Number <br />AM <br />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 />information 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 1_1_I fL(m) JJ_Jin.(cm) 1_1 above or 1_I 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 floorelevated in accordance with the community's <br />floodplain management ordinance? 1-1 Yes' 1_I 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 />Afflk <br />RESS 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 Jo 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 it�em(s) and sign belo�v. <br />G1. I-1 The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, <br />en Ineer,;or,&chitect who is authorized by state or.local law to certify elevation information. (Indicate the source and date of the <br />elevation data• a he. Comments area below.) <br />G2. 1_I 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. LI The following information (Items G4-139) i$ provided for community floodplain management purposes. <br />1 G5. <br />I ISSUED <br />G7. This permit has been -issued for: 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 gQflooAnq.at the buildinp site, is: - _ ft.(m) Datum: <br />S NAME Er►gineering Division has reviewed TITLE <br />COMMUNITY NAME rr!! Jevation Certificate and TELEPHONE <br />t �"f�����Rv�iu� <br />SIGNATURE DATE <br />does not recommend <br />AMENTS 0_Qnaf approval. <br />Check here if attachments <br />F=PKAA Farm R1 .21 AI Ir; CIO <br />