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oSep 29 05 03:09p Public Works 808-327-3533 p•2 IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use: BUILDING STREET ADDRESS (Including Apt., Unit, cite, and/or Bldg. No.) OR P.O. ROUTE ND BOX NO. Policy Number (n9 - { 92 Puq k5e c /� CITY mqQ l n STATE qZIP b14 Company NAIC Number rC` 1 ` 1 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 LJ Check here it attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REOUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zo a -AQ and Zone A (without BFE), complete Items E1. through E5. If the Elevation Certificate is intended -for use -as supporting information for a L'OMAor LOMB -F, Section C must be completed. `- E1. Building Diagram Nu, mb`et (Select the building diagram most similar to the building..forwvch this certificate is being completed -- see pages 6 and 7. If no diagram ci u Lely represents the building, provide a s�etch or photograph.) E2. The top of the bottom floor (including basement.pr enclosure) of the buil ' -it; L& ft- (m) j (- (in. (cm) L) above or L_I below (check one) the highest adjacent grade. (Use natu et -grade, if avaitgue.) E3. For Building Diagrams 6-8 with openings (seepage 7),..the n' kt higher floor or elevated floor (elevation b) of the building is (1 -71 ft. (m)11 12 din. (cm) above the highest-adtacent grade. Co pTete-Ile its C3.h and C3.i on front of form. E4. The top of the platform of machinery a+�dlor equipment servicing the building is Left (m) (l L( in. (cm) L)�J above or LI below (check one) the highest adj�nt reg de. (Use natural grade, if available.) ��—• E5. For Zone AO only. I�ffood depth number is available, is the top of the bottom Floor elevated in accordance with the community's floodplain managefneni ordinance? 1 ( Yes ( ( No i 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 C3J only), and E for Zone A (without a FEMA -issued or community -issued BFE) or Zone AO must sign here. rhe statements in Sections A. B, C, and E are correct to the best of my knowfedpe. 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. (^( 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. I I 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 foilowing information (Items 1134-139) is provided for community floodplain management purposes. G4. PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCEIOCCUPANCY ISSUED G7. This permit has been issued for: 1_1 New Construction �,_I Substantial Improvement G8. Elevation of as-buitt 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 l _1 Check here if attachment; FEMA Form 81-31, January 2003 Replaces all previous editions