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L -LVH iuN CERTIRCATE OMB ..� <br />EXPIRES: JUNE 30 1; <br />FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM <br />This form is to be used for: 1) Post -FIRM construction only when the base flood information is available for the building site; and 2) Pre -FIRM buildings rated using Post -FIRM rules. <br />Instructions for completing this form can be found on the reverse side. <br />BUILDING OWNER'S NAME <br />L.07 a-2 -457- /'�A WA r SNI ST -TH Z <br />ADDRESS <br />POLICY NUMBER <br />i --- SAA, 7 rnr "7 <br />Apt. -Al Unit -U Suite-SlBldg.-B NO. ROUTE BOX NUMBER <br />4:�2- Z.2- - <br />OTHER DESCRIPTION (Block and lot numbers., etc.) <br />4-14-0 72p <br />CIN STATE ZIP CODE <br />This form is to be completed by a land surveyor, engineer, or architect who is authorized by state law to certify elevation information when the elevation <br />information for zones Al A30, AE, AH, A(with BFE), V1 -V30, VE, and V(with BFE) is required. In the case of zone AO, the building official, the property <br />owner, or the owner's representative should complete the information in Section I and may also complete the certification. Community officials who are <br />authorized by local law or ordinance to provide floodplain management information may also complete this form. <br />SECTION I BUILDING ELEVATION INFUHMAI1UN <br />1. Using the Flood Insurance Manual or the NFIP Flood Insurance Application—Part 2 Worksheet, indicate the proper diagram number <br />2. FIRM Zones Al -A30, AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an <br />elevation of 40A 0 feet NGVD. (or other datum -see #5) <br />3. FiRM Zones V1430, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level floor from <br />the selected diagram is at an elevation of feet NGVD (or other datum -see #5). <br />4. FIRM Zone AO. The floor used as the reference level from the selected diagram is W feet above highest natural grade next to <br />the building (also enter in line 8). This value must be equal to or greater than the AO Zone flood depth number listed below. If no <br />flood depth number is available; is the building's lowest floor (or reference level) elevated in accordance with the community's <br />floodplain management ordinances? ❑ Yes ❑ No ❑ Unknown .,% <br />5. Indicate the elevation datum system used in determining the above reference levVN(GVD <br />vations:[] NGVD 5 other (describe on back) <br />6. indicate the elevation datum system used on the FIRM for base flood elevations: ❑ Other (describe on back) <br />(ATTENTION: if the elevation datum used in measuring the elevations is different than that used on the FIRM, then the elevations provided <br />must be converted to the datum system used on the FiRMM..,)// <br />07. Is the reference level based on actual construction? 1.V1 Yes ❑ No' <br />' A "No" answer is only valid if the building does not have the reference level floor in place. Fill in the elevation based on construc- <br />tion drawings and do not complete question #8. If "No" is checked, this certification will be valid.oniy for buildings in the course of <br />construction. After construction of the reference level floor is completed, a post -construction elevation certificate will be required for <br />continued flood insurance coverage. <br />8. Provide the following measurements using the natural grade next to the building (round to the nearest foot). <br />!D, Sa. The referenc evel is: b. The garage'flogr (if applicable) is: <br />feet ove EJ below (check one) the highest grade. I , I:of feet 6Zbove ❑ below (check one) the highest grade. <br />10c) feet above ❑ below (check one) the lowest grade. � feet above ❑ below (check one) the lowest grade. <br />SECTION 11 FLOOD INSURANCE RATE MAP INFORMATION <br />Provide the following from the proper FIRM (see Instructions on back -Date of FiRM) and accompanying insurance application: <br />COMMUNITY NO. <br />PANEL NO. <br />UFFIX <br />DATE OF FIRM <br />FIRM ZONE <br />BASE FLOOD ELEV. <br />M NI IMA BASE FLOOD <br />(In AO Zone, use depth) <br />ELEVATION ESTABLISHED FOR'ZONE A <br />A4 <br />OO <br />I <br />�� �Qb a <br />^�r D <br />OR ZONE VtIF AILABLE <br />Elevation reference mark used appears on FIRM ❑ Yes [ONO (See reverse side for details) <br />SECTION III CERTIFICATION <br />This certification is to be signed by a land surveyor, engineer, or architect who is authorized by state law to certify elevation information when the <br />elevation information for zones Al -A30, AE, AH, A(with BFE), Vl-V30, VE, and V(with BFE) is required. In the case of zone AO, the building official, the <br />property owner, or the owner's representative can sign the certification. Community officials who are authorized by local law or ordinance to provide <br />floodplain management information, may also sign the certification. I certify that the information on this certificate represents my best efforts to interpret <br />the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. <br />THIS FORM MAY BE REPRODUCED. <br />FOR OPTIONAL COMMUNITY USE: is the reference level also the lowest floor under the community's floodplain management ordinances? <br />El YES ONO If NO the elevation of the lrrvvwat flnnr is loaf furvn <br />