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IMPORTANT, In these spaces, copy the corresponding infonmatlon from Section A. WFor InsiAkipce Company Use: BUILDING STR 7 ADDRESS Including Apt., U ll, Suite; and/or Bldg: No, OR P.O. ROUTE AND BOX NO. Policy Number �9— e �0141<o �F1fC# . fir,,. 4. 4,o7~ / */ CITY STATE, ZIP CODE Company NAiC Number SECTION D - SURVEYOR,--ENGINEER:;!,-,OR ARCHITECT CERTIFICATION (CONTINUED) py both sides of this Elevation Certificate for (1) community official, -(2) insurance agent/company;-and (3) building owner. Tf1,6 , /s ys/i ryry 7ff.E N 4, l—I 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 E5. if 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 1_1_1 ft. (m) I -1_I in. (cm) i_I above or 1!1 below (check one) the highest adjacent grade. (Use natural grade, (f`available.) E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (eleyation b) of the building is I -1_I ft. (m) 1,1_Iin. (cm) above the highest adjacent grade. Complete Items C3.h and C3J on front of form. E4. The top of the platform of machinery and/or equipment servicing the building is 1_1_1 ft. (m)1_1in. (cm) 1_1 above or 1,1 below (check one) the highest adjacent grade. (Use natural grade, [f available.) E5. 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 I Yes 1__1 No 1: 1 Unknown. The local official must ceelify-this information in Section G. SECTION F - PROPERTY OWNER (OWOWNER'S REPRESENTATIVE) CERTIFICATION , The property owner or owner's authorized representative who completes Sections A, B, C (Items C3.b and C3J only), and E for Zone A (without a FEMA -issued or community -issued BFE) or Zonee-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 CODE 'NATURE DATE TELEPHONE COMMENTS SECTION G.; --COMMUNITY INFORMATION (OPTIONAL)'. Check here it attachments 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. Coihplete the applicable item(s) and sign' eiow. G1. 1_1 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. 1. G3. 1_i The following information (items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER I G5. DATE PERMIT ISSUED I ATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7. This permit has been issued for: 1_1 New Construction I�I Substantial Improvement G8. Elevation of as -built lowest floor (including basement).of•the building is: —ft. (m) Datum: G9. BFE or (in Zone AO) dgpth oploodin at i e b it e ' T ft. (m) Datum: :arra oft%arks LOCAL OFFICIAL'S NAME"3 ivts:L�ri l't5 e TITLE COMMUNITY NAME r ' y6 TELEPHONE cis SIGNATURE i"- i =:es)not recorntttertd DATE COMMENTS t tr'1 cc Ase I 2- 03--. I I Check here it attachments FEMA Form 81-31, January 2003 Replaces all previous editions