|
U.S. DEPARTMENT OF HOMELAND SECURITY
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />VE-onol Flood Insumme Program
<br />Al. Building Owner's Name
<br />A2. Building
<br />City
<br />ELEVATION CERTIFICATE
<br />IMPORTANT: Follow the instructions on pages 1-9.
<br />SECTION A - PROPERTY INFORMATION
<br />or P.O. Route
<br />OMB No. 1660.0008
<br />Exp ration Date: July 31, 2015
<br />FOR INSURANCE COMPANY USE
<br />Policy Number'
<br />Company NAIC Number
<br />ZIP Code 96 7�
<br />A3. Property Descd tion (Lot and BI ck Numbers, Tax Parcel N tuber, ivegal Description, etc.) t7
<br />A4. Bu.lding Use (e.g., Residential, Non -Res { enpal, Addition, Accessory, etc.
<br />A5. Latitude/Longitude: Lat. / % •9r Long. Horizonta Datum: ❑ NAD 1927 KNAD 1983
<br />A6. Attach at least 2 photographs of he building 'f the Certificate s being used to obta'r flood nsurance.
<br />A7. Building Diagram Number
<br />A8. For a build:ng with a crawispace or enclosure(s): �/1 /1 A9. For a bu d g with an attached garage: , /,�
<br />a) Square footage of crawispace or enclosure(s) � 0 sq `t a) Square outage'
<br />of attached garage � sq ft
<br />b) Number of permanent flood open ngs n the craw'space b) Number of permanent flood open ngs',n the ^ed garage
<br />or enclosure(s) with'n 1.0 foot above adjacent grade within 1.0 foot above adjacent grade
<br />c) Tota net area of flood open:ngs in A8.b sq 'r c) Tota net area of flood open ngs `n A9.b i� sq :n
<br />d) Engineered l'ood openings? 5rYes ❑ No d) Eng'neered flood open ngs? ❑ Yes ,® No
<br />SECTION B - FLOOD INSURANCE RATE MAP (Ft
<br />81. NFIP Commun'ty Name & Community Number B2. County N me
<br />NAIVA/ 100v SSS /66 pull//
<br />INFORMATION
<br />(IOU,
<br />B4. Map/Pane) Number B5. Sufxx I B6. FIRM Index Date B7. FIRM Panel Effective/ B8. Flood Zon (s
<br />t9g, �j{j �� e. ¢�0 2
<br />iRevind to A
<br />B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9:
<br />❑ FIS Profile ❑ FIRM ❑ Community Determined 50 Other/Source: EA16/A/E&VA0 (7214X0
<br />811.ln&cate elevation datum used for BFE in Item B9: ❑ NGVD 1929 J4 NAVD 1988 ❑ Other/Source:
<br />812. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA'?
<br />Designation Date: / / ❑ CBRS ❑ OPA
<br />B3.
<br />- i f&W)A
<br />B9. Base Flood Elevation(:
<br />A0, use base flood de,
<br />❑ Yes ,kNo
<br />SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
<br />Cl. Build ng elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction*
<br />1% Fin shed Construction
<br />*A new Elevation Certificate will be requ red when construction of the budding is complete.
<br />C2. E evations - Zones Ai -A30, AE, AH, A (with BFE), VE, Vi -V30, V (with BFE), AR, AR/A, AR/AE, AR/Al-A30, AR/A
<br />, AR/A0. Complete items
<br />C2.a-h below according to the building diagram specified in item A7. In Puerto Rico on+y, enter meters.
<br />Benchmark Utilized:-C,flAi1I&IM JAJV' "T- Vertical Datum:
<br />,
<br />Ind cate elevation datum used for the elevations n tems a) through h) below. ❑ NGVO =929 ® NAVD 1988
<br />(3 Other/Source:
<br />Datum used for bu ldmg elevations must be the sa a as tha sed for the BFE.
<br />Z� Check the measurement used.
<br />a) Top of bottom floor (•nclud ng basement, crawispace, or enc osure oor) �_ [fffeet ❑meters
<br />b) Top of the next higher floor_
<br />❑feet
<br />❑meters
<br />c) Bottom of the lowest horizontal structura member V Zones on y) I_
<br />❑ feet
<br />❑ meters
<br />d) Attached garage (top of slab) ,1) . 1L
<br />E(eet
<br />❑ meters
<br />e) Lowest elevation of machinery or equipment servic ng the bu Id g 3 . 9��
<br />Wfeet
<br />❑ meters
<br />(Describe type of equipment and :ocat on in Comme is 2�d
<br />f) Lowest adjacent (fin',shed) grade next to bu Id'ng LAG) ✓r4
<br />��
<br />[E fee:
<br />❑ meters
<br />g) Highest adjacent (finished) grade next to building (HAG)3i S'
<br />et
<br />❑ meters
<br />h) Lowest adjacent grade at lowest eievation of deck or stairs, inc ud ng .
<br />Vf�eet
<br />❑ meters
<br />structural support
<br />SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
<br />Th s certification .s to be s gned and sealed by a land surveyor. engineer, or architect authorized by law to certify eleva,,on
<br />.ormation. I certify ti at a nformat+on on tris Certificate represents my best efforts to Interpret the data ava-lab e
<br />understand that any fa se statement may be pun'shable by fine or imprisonment under 18 U.S. Code, Section 1001 A. M,q
<br />Check nere i co a is are prov ded o- back of orm. Were latitude and longitude n Sect on A provided by a Qp' sy
<br />❑ Check here if attac ents. licensed land surveyor? ❑ Yes PKNo
<br />ro.rise.•� �;�.,,e _REGIST�
<br />Fn
<br />•4.
<br />Title n/L//L
<br />Add,ess P ^
<br />Sigrat,ae
<br />FEMA Form 086-0.33 (Revised 7/12)
<br />`Va^`eG//uGG
<br />L-0.
<br />'^ State 4,
<br />Z9p,�gd�
<br />/� TIF o e 965 7 �
<br />See reverse side for continuation.
<br />ENGIN ME
<br />HERE
<br />No. 7469-C /
<br />Replaces all previous editions.
<br />
|