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FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />NATIONAL FLOOD INSLIRANCE PROGRAM
<br />ELEVATION CERTIFICATE
<br />• Important: Read the Instructions on pages 1 - 7. _
<br />SECTION A - PROPERTY OWNER INFORMATION
<br />BUIZeG OWNER'S 4ME
<br />BUILDING STREET ADD/7t/-4
<br />R€SS (Indudi Apt.. Unit. Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
<br />7 B- Ie)9f+ /7t /- c -4
<br />CITY - -. , STATE
<br />—PROPERTY DESCRIPTION (Lot and Bim' um er!,am aQ um �;_�p� etc.)
<br />1,
<br />O.M.B. No. 3067-0077 O
<br />Expires July 31, 2002
<br />For Insurance
<br />LATITUDEILONGITUDE (OPTIONAL) ' �n HORIZONTAL DATUM: : LI (Type):
<br />Rs,W or 0.i 06) Ipl NAD 1927 " NAD 1963 LJ USGS Quad Map I --I 011ier. Co v .v r B M
<br />SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
<br />B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered In B9.
<br />Lj FIS Profile * FIRM IJ Community Determined I_j Other (Describe):
<br />811. Indicate the elevation datum used for the BFE in B9: JXJ NGVD 1929 LJ NAVD 1988 U Other (Describer
<br />B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPAJ? Lj Yes QSJ No
<br />Designation Date:
<br />SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
<br />•
<br />I. Building elevations are based on: I_jConstruction Drawings' - "Building Under Construction* &6Finished Construction
<br />•A new Elevation Certificate will be required when construction of the building is complete.
<br />C2. Building Diagram Number / (Select the building diagram most similar to the building for which this certificate is being completed -see
<br />pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.)
<br />C3. Elevations - Zones At -A30, AE, AH, A (with BFE), VE, V1430, V (with BFE), AR, AR/A, ARAE, AR/A1-A30, AR/AH, ARIAO
<br />Complete Items C3.a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from
<br />the datum used for the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion
<br />calculation. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
<br />Datum _ Conversion/Comment
<br />Elevation reference mark used _e ' 2f s /l Does the elevation reference mark used appear on the FIRM? L_j Yes jX1 No
<br />O a) Top of bottom floor (including basement or enclosure)
<br />B4. MAP P
<br />77
<br />nn sA E
<br />85 1. CDATE
<br />INDEX
<br />87. FIRM PANEL
<br />EFFECTIVFJREVISED DATE
<br />88. FLOOD
<br />ONE(S)
<br />89. BASE FLOOD per of floadirg))
<br />(Zone AO, use doIRM
<br />_ ft.(m) 0 0
<br />O d) Attached garage (top of slab)
<br />2
<br />__rp ❑ e) Lowest elevation of machinery and/or equipment
<br />a e
<br />B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered In B9.
<br />Lj FIS Profile * FIRM IJ Community Determined I_j Other (Describe):
<br />811. Indicate the elevation datum used for the BFE in B9: JXJ NGVD 1929 LJ NAVD 1988 U Other (Describer
<br />B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPAJ? Lj Yes QSJ No
<br />Designation Date:
<br />SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
<br />•
<br />I. Building elevations are based on: I_jConstruction Drawings' - "Building Under Construction* &6Finished Construction
<br />•A new Elevation Certificate will be required when construction of the building is complete.
<br />C2. Building Diagram Number / (Select the building diagram most similar to the building for which this certificate is being completed -see
<br />pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.)
<br />C3. Elevations - Zones At -A30, AE, AH, A (with BFE), VE, V1430, V (with BFE), AR, AR/A, ARAE, AR/A1-A30, AR/AH, ARIAO
<br />Complete Items C3.a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from
<br />the datum used for the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion
<br />calculation. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
<br />Datum _ Conversion/Comment
<br />Elevation reference mark used _e ' 2f s /l Does the elevation reference mark used appear on the FIRM? L_j Yes jX1 No
<br />O a) Top of bottom floor (including basement or enclosure)
<br />Z 4 .2 / ft.(m)
<br />ft.(m) 'g%
<br />U b) Top of next higher floor
<br />_
<br />❑ c) Bottom of lowest horizontal structural member (V zones only)
<br />_ ft.(m) 0 0
<br />O d) Attached garage (top of slab)
<br />2
<br />__rp ❑ e) Lowest elevation of machinery and/or equipment
<br />a e
<br />servicing the building (Describe in a Comments area.)
<br />O f) Lowest adjacent (finished) grade (LAG)
<br />Z 0 .
<br />TTS
<br />L ft.(m) 1
<br />y„ N
<br />O g) Highest adjacent (finished) grade (HAG)
<br />2 y .
<br />�)o ft.(m)
<br />O h) No, of permanent openings (flood vents) within 1 ft. above adjacent
<br />grade
<br />(a i) Total area of all permanent openings (flood vents) in C3.h
<br />sq. in. (sq.
<br />cm)
<br />SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
<br />This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation intorieation.
<br />I certify that the inks A, B. and C on this certificate represents my best efforts to interpret the'deta available.
<br />I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.'
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