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Home My WebLink About1-4-067:012FEDERAL 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' r1% Policy Number om L BUILDING STREET A RES s(1ndl inP6�t.; Unit, Suite, and/or Bldg. No.)) OR P.O. ROUTE AND BOX NO. Company NAIC Number 14j- 6 CAJGi �bnd� STI��PiT CITY STATE ZIP CODE :- = WX 9 67 8 PROPERTY DESaRtIPTIO1I-(Lot and BlockrNumbers, Tax Parcel Number, Legal Description, etc.) l ti 0c; tJlie41toti lays e /141.,&ii La!- tZ 1 BUILDING USE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use Comments section`if necessary.) LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: LI GPS (Type) ( W - ##' - ##.W or ##.#####°) IJ NAD 1927 1_1 NAD 1983 I_I USGS Quad Map 1_1 Other. SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION ' B1. COMMU,N�I-TS/i ME &COMMUNITY NUMBER 162. COUNTY NAME I 63. S�;T�wa!-/, . B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL B8. FLOOD B9: BASE FLOOD ELEVATIONS) NUMBER C DTE G/Z f5" EFFECTIVE/REVISED DATE ZONE S) VL-(' (Zone AO, use depth of flooding) 14ov q- IG- >; s l S.t�o B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. 1_I. FIS Profile . IJ FIRM I_1 Community Determined Ll Other (Describe): B11. Indicate the elevation datum used for the BFE in 139: 1J NGVD 1929 1J NAVD 1988 1_1 Other (Describe): 812. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 1J Yes 1J No Designation Date: A11A SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) 41. Building elevations are based on: 1_1Construction Drawings' 1_113uilding Under Construction' 1,&IFinished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number S (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, ARIA, AR/AE, 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 M -5L Conversion/Comments Elevation reference mark used Does the elevation reference mark used appear on the FIRM? 1_1 Yes 1?CJ No Q a) Top of bottom floor,(including basement or enclosure) / 7 7 fL(m) ❑ b) Top of next higher floor AlAq _ ft.(m)CU ❑ c) Bottom of lowest horizontal structural member (V zones only) / S ft.(m) ❑ d) Attached garage (top of slab) 3 Jr ft.(m) E ❑ e) Lowest elevation of machinery and/or equipment W' d servicing the building 1-7 7 ft.(m) W ❑ f) Lowest adjacent grade (LAG) Z S ft.(m) z' ❑ g) Highest adjacent grade (HAG) 3 fL(m) ❑ h) No, of permanent openings (flood vents) within 1 ft. above adjacent grade AIIA ❑ i) Total area of all permanent openings (flood vents) in C3h NIA sq. in. (sq. cm) —1 LICENSED = PA FESSIONAL � LAND SURVEYOR :br � Iia W77 P� 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. I certify that the information in Sections A, 8, and C on this certificate represents my best efforts to interpret the data available. t understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. ERTIFIER'S NAME LICENSE NUMBER IViets CG�r�sfenseK 9077 TITLE 54,rvP ya r- COMPANY NAME ADDRESS I o 4 + /1 ,fi /; wqy CITY 14.1. STATE/41- ZIP CODE 9672 O SIGNATURE ///%��j• / DATE TELEPHONE TELEPHONEopoe 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 7 CITY STATE ZIP CC( Company NAIC Number SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, aid (3) building owner. COMMENTS - C-) heck here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO and Z0_1 A (WITHOUT BFE) For,Zone AO and Zone A (without BFE), complete Items E1 through E3. If the Elevation Certificate is intended for-4use as supporting information for a LOMA or LOMR-F, Section C: must be completed. E1. 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 1_1-1 ft.(m) 1_1—lin.(cm) 1-1 above or 1_1 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? 1_1 Yes' 1_1 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. PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME Aft 44WRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE COMMENTS 1-1 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. 1_1 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 information (Items G4 -G9) is provided for community floodplain management purposes. G7. This permit has been issued for: 1_1 New Construction 1_1 Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m) Datum: G9. BFE or (in Zone AO) deXtth%fR*WWlX ih6 to *ttWJLie iWorks _ ft.(m) Datum: LOCAL OFFICIAL'S NAME s reviewed TITLE recommends GNATURE u does not recommend DATE Check here if attachments