6-5-003:029 Re-Located Old Church

Home

IMPORTANT:,•In thesespaces,copy the corresponding information from Section A. .• For Insurance Company lice. BUILDING STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Policy Number CITY STATE ZIP CODE Company NAIC 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 BFE) For Zone AO and Zone A(without BFE),complete Items El.through E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F,Section C must be completed. El.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 I__I__I ft.(m)I (�lin.(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 1_1_1 ft.(m)l--l--lirt.(cm)above the highest adjacent grade. Complete Items C3.h and C3.i 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?I_I Yes I_.1No II 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 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.I__I The information in Section C was taken from other documentation that has been signed and embossed bye 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.I=_I 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: LI 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!O).depth of flooding at the building site is: ft.(m)Datum:_________ LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE The Department of Pdbtic Vi-crridE COMMENTS Engineering Divisien has- reviewwccd the Elevation Certificate and I recommends ID does not recommend I__I Check here if attachments finul upptuvul FPIAA Fetrm R1-'%1 II ti nn PFPI A(:FC AI I PRF\/t ll IC Pr11TIr1NC By Date Ct, S( 02--