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IM1R'ORTANT: In these spaces, co the corresponding informatidn from Section A. For Insurance Cc BUILDING STREET ADDRESS (Including Apt., Unit, Suite, andlor Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number CIfY�U��O �'( j9�!r✓�Gr4 STATE`7,1-3 ZIP CODE Company NAIC t SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenticompany, and (3) building owner. %A %95 d422---7- 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 E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMB -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 {JJ ft•(m) JJ.Jim(cm) I _I above or I I 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 JJ J ft -(m) I_,J_Jin.(cm) above the highest adjacent grade. Complete Items C3.h and C33 on front of form. 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? (_{ Yes Irl No I_I 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. PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CWE Slij A URE DATE TELEPHONE COMMENTS IJ 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, 8, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. G1. JJ 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. J_J 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 The following information (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7. This permit has been issued for. 1J New Construction J_ j 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: LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS Check here if attachments orFKAA Fnrm R1_31 _1111 nn RFPI Ar.FG Al I PRFVlr111R r-F)1Tlr)N.R