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ELEVATION CERTIFICATE, page 2 IMPORTANT: in these spaces, copy the corresponding Information from Section A. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P0. Route and Box No. 235(-, c c�_—__-- City State ZIP Code FOR INSURANCE COMPANY USE Policy Number: r -r t✓ 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 //v MAC141 Nay 6F&OW EMS6_, (D j> �iC✓�%/0/i� Signature Date ,3/Z5 SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zones AO and A (without BFE), complete Items E1 -E5. if the Certificate is intended to support a LOMA or LOMB -F request, complete Sections A, B,and C. For Items E1 -E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or b) Top of bottom floor (including basement, crawls pace, or enclosure [:] below the HAG. ) is ❑feet El ❑ above or F1 below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9 (see pages 8-9 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is ❑ feet ❑ meters ❑ above or E3. Attached garage (top of slab) is EJ below the HAG. ❑ feet ❑ meters ❑ above or ❑ below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is ❑ feet ❑ meters ❑ above or ❑ below the HAG. E5. 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? ❑ Yes ❑ No ❑ 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. The statements in Sections A, B, and E are correct to the best of my knowledge. Property Owner or Owner's Authorized Reprets�egqtative's Name , PA V i ,eS. tht A SF -i Address ❑ 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. Check the measurement used in Items G8 -G10. In Puerto Rico only, enter meters. G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. ❑ A community official completed Section E for a building located in Zone A (without a FEMA -issued or community -issued BFE) or Zone A0. G3. ❑ 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: ❑ New Construction ❑ Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building: ❑ feet ❑ meters Datum G9. BFE or (in Zone AO) depth of floodif at % i site,El feet ❑meters Datum _ G10.Community's design flood eievatio en' "f PUbil" orr ❑feet ❑ meters Datum ft ine67; Local Official's Name file Elevatien Certificate and We Community Name f6?P1k nds Tel2pl one 401 Signature L -J 1-1 reom' -tend Qate• anc_I approval Comments By Date � 1)� ❑ Check here if attachments FEMA Form 086-0-33 (7/12) Replaces all previous editions.