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Cl �Iwnvu sv Ktt r °ADDRESS (Including=APL; ' Suite,;aiid/or Bldgr No:) OR P.O. ROUTE STA ZIP CODE _... ,mal ly,vse: Policy 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 I_I Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT SFE) For Zone AO and Zone A (without BFE), complete Items E1 through E4. !f 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 IJ—I ft.(m) IJJin.(cm) U above or 1__1 below (check one) the highest adjacent grade. E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is U_1 ft.(m) U_1in.(cm) above the highest adjacent grade.. E4. 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, 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 ADDRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE COMMENTS U 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. U 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. U 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. LJ O.G3.1_1 The foil 0wing information (Items G4-139) is provided for community floodplain management purposes. ISSUED 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) depth of flooding at the building site is: _ ft.(m)Datum: Engineering Division has reviewed 1116C COMMUNITY NAME the Elevation Certificate and TELEPHONE SIGNATURE reMinmends DATE does not recommend COMMENTS final approval PrIMA Pnrm R1_ 21 AI Ir, as Check here if attachments RGDI Ar`GC Al 1 PPM/Ir1114Z Gr11T1(IAI4Z