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rsUIwwc;=S I KtL I ADDRESS(Including-Apt,' Suite,.and/or Bldg:'No.)OR P.O. ROUTE AND BO: 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 _. 1-1 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)1 I iin•(cm) I-1 above or 1_1 below (check one)the highest adjacent grade. E3.For Building Diagrams 6-8 with openings(see page 7),the next higher floor or elevated floor(elevation b)of the building is I 1J ft•(m)I I_Iin.(cm)above the highest adjacent grade. 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?1_1 Yes (_J No 11 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,and E for Zone A(without a FEMA-issued or community-issued BFE)or Zone AO must sign here. PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE COMMENTS ( 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. G 1.1 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 1 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: I1 New Construction 1_1 Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building is: _ft.(m)Datum: G9. BFE or(in Zone AO)deoth ofgoodin at the b 'Id'nggsite is: ft.(m)Datum: •Pne epartmenf of Public VAinrkc LOCAL OFFICIAL'S NAME Engineering Division has reviewed TITLE COMMUNITY NAME the tlevation Ctificate ander TELEPHONE Jr1} recommends SIGNATURE DATE 0 does not recommend COMMENTS final approval By �9 Dude 012,1102- 1_1 Check here if attachments FP RA Fnrm Pt I_11 M I(.00 PDI ACPC GI I DDFVnnI Ic FnITInnIc