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FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077 NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002 ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION For Insurance Company Use: BUILDING OWNER'S NAME' r1% Policy Number om L BUILDING STREET A RES s(1ndl inP6�t.; Unit, Suite, and/or Bldg. No.)) OR P.O. ROUTE AND BOX NO. Company NAIC Number 14j- 6 CAJGi �bnd� STI��PiT CITY STATE ZIP CODE :- = WX 9 67 8 PROPERTY DESaRtIPTIO1I-(Lot and BlockrNumbers, Tax Parcel Number, Legal Description, etc.) l ti 0c; tJlie41toti lays e /141.,&ii La!- tZ 1 BUILDING USE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use Comments section`if necessary.) LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: LI GPS (Type) ( W - ##' - ##.W or ##.#####°) IJ NAD 1927 1_1 NAD 1983 I_I USGS Quad Map 1_1 Other. SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION ' B1. COMMU,N�I-TS/i ME &COMMUNITY NUMBER 162. COUNTY NAME I 63. S�;T�wa!-/, . B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL B8. FLOOD B9: BASE FLOOD ELEVATIONS) NUMBER C DTE G/Z f5" EFFECTIVE/REVISED DATE ZONE S) VL-(' (Zone AO, use depth of flooding) 14ov q- IG- >; s l S.t�o B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. 1_I. FIS Profile . IJ FIRM I_1 Community Determined Ll Other (Describe): B11. Indicate the elevation datum used for the BFE in 139: 1J NGVD 1929 1J NAVD 1988 1_1 Other (Describe): 812. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 1J Yes 1J No Designation Date: A11A SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) 41. Building elevations are based on: 1_1Construction Drawings' 1_113uilding Under Construction' 1,&IFinished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number S (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.) C3. Elevations - Zones Al -A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, ARIA, AR/AE, AR/A1-A30, AR/AH, AR/AO Complete Items C3a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from the datum used for the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion calculation. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion. Datum M -5L Conversion/Comments Elevation reference mark used Does the elevation reference mark used appear on the FIRM? 1_1 Yes 1?CJ No Q a) Top of bottom floor,(including basement or enclosure) / 7 7 fL(m) ❑ b) Top of next higher floor AlAq _ ft.(m)CU ❑ c) Bottom of lowest horizontal structural member (V zones only) / S ft.(m) ❑ d) Attached garage (top of slab) 3 Jr ft.(m) E ❑ e) Lowest elevation of machinery and/or equipment W' d servicing the building 1-7 7 ft.(m) W ❑ f) Lowest adjacent grade (LAG) Z S ft.(m) z' ❑ g) Highest adjacent grade (HAG) 3 fL(m) ❑ h) No, of permanent openings (flood vents) within 1 ft. above adjacent grade AIIA ❑ i) Total area of all permanent openings (flood vents) in C3h NIA sq. in. (sq. cm) —1 LICENSED = PA FESSIONAL � LAND SURVEYOR :br � Iia W77 P� SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the information in Sections A, 8, and C on this certificate represents my best efforts to interpret the data available. t understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. ERTIFIER'S NAME LICENSE NUMBER IViets CG�r�sfenseK 9077 TITLE 54,rvP ya r- COMPANY NAME ADDRESS I o 4 + /1 ,fi /; wqy CITY 14.1. STATE/41- ZIP CODE 9672 O SIGNATURE ///%��j• / DATE TELEPHONE TELEPHONEopoe