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Home My WebLink About2-4-037:047FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077 NATIONAL FLOOD'INSURANCE PROGRAM Expires July 31, 2002 ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION For Insurance Company Use: BUILDING OWNER'S NAME Policy Number SOUTH -1 SQASL.`E:S D�vZ�t�wt7T �+v� BUILDING STREET ADDRESS (Inclyding Apt., Unit, Suite, and/qr pldg. No.) OR P.Q. RCQTE AND BOX NO. Company NAIC Number / STATE ZIP CODE CITHI'LO zo PROPERTY DESCRIPTION (lot and ;Block Numbers, Tax Parcel Number, Legal Description, etc.) (-" s ID t`'ST' t 1A=1_ LATITUDE/LONGITUDE (OPTIONAL) ( Mr - ##' - ##.#r or ##.#####0) etc. Use Comments section if necessary.) HORIZONTAL DATUM: SOURCE: IJ GPS (Type] LJ MAD, 1927 W NAD 1983 IV USGS Quad Map "Other. SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION Bl. NFIP: COMMUNITY NAME 8 COMMUNITY NUMBER 62. COUNTY NAME B3. STATE HWdj4ki( ISSIWa 04kUJ1(( I HA"(� 84. MAP AND PANEL I B5. SUFFIX I B6. FIRM INDEX 1 87. FIRM PANEL I B8. FLOOD I B9. BASE FLOOD ELEVATION( 1 NUMBERDgTE EFFEC IVEIREVISED DATE ZONE(S) (Zone AO, use depth of flooding) csSieta a ; o c 6 1-1 . Qr 1 1 16 &AZIC 610. Indicate the source of the Base flood Elevation (BFE) data or bdsle flood depth entered in B9. 1_1 FIS Profile IN -FIRM U Community Determined U Other (Describe) 611. Indicate the elevation datum used, for the BFE in B9:1X NGVD 1929 (_j NAVD 1988 (J Other (Describe): B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? U Yes LANo Designation Date: SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Nfaw C1. Building elevations are based on::jJConstruction Drawings` uBuilding Under Construction` I.91Finished Construction •A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number -_C,' (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.) C3. Elevations - Zones Al -A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, ARAE, AR/A1-A30, AR/AH, AR/AO Complete Items C3a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from the datum used for the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion calculation. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion. Datum Conversion/Comments Elevation reference mark used US& S 64 Does the elevation reference mark used appear on the FIRM? 1_1 Yes [k) No ❑ a) Top of bottom floor (including basement or enclosure) mm) d ❑ b) Top of next higher floor N�i4 _ ft.(m) O c) Bottom of lowest horizontal structural member (V zones only) AJI-4 ft. (m) -,-g ❑ d) Attached garage (top of slab) 612 . :y ft.(m) E ❑ e) Lowest elevation of machinery and/or equipment W d servicing the building �✓'�� walob 2 ft.(m) E is O f) Lowest adjacent grade (LAG) ��cv _ ft(m) ❑ g) Highest adjacent grade (NAG) CjJ mm) ❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade AJIA- --- i) Total area of all permanent openings (flood vents) in C3h sq. in. (sq. cm) • SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. 1 certify that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available. understand that anv false statement may be punishable by line or imprisonment under 18 U.S. Code. Section 1001. IMPORTANT: In these spaces, copy the corresponding information from .Section A. For Insurance Company Use: BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number CITY STATE ZIP Cd Company NAIC Number dh 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. 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 E1 through E3. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F, Section C must be completed. Ef. 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 J_jJ ft.(m) LJJ1n.(cm) L above or LJ below (check one) the highest adjacent grade. E3. 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? JJ Yes' JJ No 1_1 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. S SIGNATURE DATE TELEPHONE COMMENTS jJ 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. G1. L_l 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. 1_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. 1_1 The following- nformatien (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBEfl G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7. This permit has been issued for. 1_1 New Construction [—I Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m) Datum: G9. BFE or (in Zone AO) depth of flooding at the buildinsite is: _ ft.(m) Datum: . Th Department �j Pe is: lhforks LOCAL OFFICIAL'S NAME Engineering Division has reviewed COMMUNITY NAME the Elevation Certificate and TELEPHONE DA GV�YIIYI GIV 1 J final approval Check here if attachments