HomeMy WebLinkAbout2-2-044:067L -LVH iuN CERTIRCATE OMB ..�
EXPIRES: JUNE 30 1;
FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM
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.
Instructions for completing this form can be found on the reverse side.
BUILDING OWNER'S NAME
L.07 a-2 -457- /'�A WA r SNI ST -TH Z
ADDRESS
POLICY NUMBER
i --- SAA, 7 rnr "7
Apt. -Al Unit -U Suite-SlBldg.-B NO. ROUTE BOX NUMBER
4:�2- Z.2- -
OTHER DESCRIPTION (Block and lot numbers., etc.)
4-14-0 72p
CIN STATE ZIP CODE
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
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
owner, or the owner's representative should complete the information in Section I and may also complete the certification. Community officials who are
authorized by local law or ordinance to provide floodplain management information may also complete this form.
SECTION I BUILDING ELEVATION INFUHMAI1UN
1. Using the Flood Insurance Manual or the NFIP Flood Insurance Application—Part 2 Worksheet, indicate the proper diagram number
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
elevation of 40A 0 feet NGVD. (or other datum -see #5)
3. FiRM Zones V1430, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level floor from
the selected diagram is at an elevation of feet NGVD (or other datum -see #5).
4. FIRM Zone AO. The floor used as the reference level from the selected diagram is W feet above highest natural grade next to
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
flood depth number is available; is the building's lowest floor (or reference level) elevated in accordance with the community's
floodplain management ordinances? ❑ Yes ❑ No ❑ Unknown .,%
5. Indicate the elevation datum system used in determining the above reference levVN(GVD
vations:[] NGVD 5 other (describe on back)
6. indicate the elevation datum system used on the FIRM for base flood elevations: ❑ Other (describe on back)
(ATTENTION: if the elevation datum used in measuring the elevations is different than that used on the FIRM, then the elevations provided
must be converted to the datum system used on the FiRMM..,)//
07. Is the reference level based on actual construction? 1.V1 Yes ❑ No'
' 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-
tion drawings and do not complete question #8. If "No" is checked, this certification will be valid.oniy for buildings in the course of
construction. After construction of the reference level floor is completed, a post -construction elevation certificate will be required for
continued flood insurance coverage.
8. Provide the following measurements using the natural grade next to the building (round to the nearest foot).
!D, Sa. The referenc evel is: b. The garage'flogr (if applicable) is:
feet ove EJ below (check one) the highest grade. I , I:of feet 6Zbove ❑ below (check one) the highest grade.
10c) feet above ❑ below (check one) the lowest grade. � feet above ❑ below (check one) the lowest grade.
SECTION 11 FLOOD INSURANCE RATE MAP INFORMATION
Provide the following from the proper FIRM (see Instructions on back -Date of FiRM) and accompanying insurance application:
COMMUNITY NO.
PANEL NO.
UFFIX
DATE OF FIRM
FIRM ZONE
BASE FLOOD ELEV.
M NI IMA BASE FLOOD
(In AO Zone, use depth)
ELEVATION ESTABLISHED FOR'ZONE A
A4
OO
I
�� �Qb a
^�r D
OR ZONE VtIF AILABLE
Elevation reference mark used appears on FIRM ❑ Yes [ONO (See reverse side for details)
SECTION III CERTIFICATION
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
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
property owner, or the owner's representative can sign the certification. Community officials who are authorized by local law or ordinance to provide
floodplain management information, may also sign the certification. I certify that the information on this certificate represents my best efforts to interpret
the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
THIS FORM MAY BE REPRODUCED.
FOR OPTIONAL COMMUNITY USE: is the reference level also the lowest floor under the community's floodplain management ordinances?
El YES ONO If NO the elevation of the lrrvvwat flnnr is loaf furvn