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U.S.DEPAF2TMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008 FEDERAL EMERGENCY MANAGEMENT AGENCY National Flood ham=Program IMPORTANT:Follow the instructions on pages 1-9. Expiration Date: July 31, 2015 SECTION A-PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Jan Nores&John Kemick Polley Number_ A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P0.Route and Box No. Company NW Number: 69-1921 PUAKO ROAD City KAMUELA State HI ZIP Code 96743 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) (3)6-9-006-036 A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Residential A5. Latitude/Longitude:Lat. 19 96196 Long. -155.85585 Horizontal Datum: ❑NAD 1927 ❑NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number 1A A8. For a building with a crawlspace or enclosure(s): A9.For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) na sq ft a) Square footage of attached garage na sq ft b) No.of permanent flood openings in the crawlspace or b) Number of permanent flood openings in the attached garage enclosure(s)within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade c) Total net area of flood openings in A8.b sq in c) Total net area of flood openings in A9.b sq in d) Engineered flood openings? ❑Yes ❑No d) Engineered flood openings? ❑Yes 0 No SECTION B-FLOOD INSURANCE RATE MAP(FIRM) INFORMATION 51. NFIP Community Name ommunity Number B2.County Name B3.State Hawaii County-1 6b HAWAII COUNTY HAWAII B4. Map/Panel Number B5.Suffix B6.FIRM Index Date B7.FIRM Panel Effective/ B8.Flood Zone(s) B9.Base Flood Elevation(s)(Zone Revised Date A0,use base flood depth) 0278C C APR 02,2004 September 16, 1988 AE 7 610.Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9: ❑AS Profile 0 FIRM 0 Community Determined 0 Other/Source: B11.Indicate elevation datum used for BFE in Item B9: ©NGVD 1929 ❑NAVD 1988 0 Other/Source: B12.Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes ID No Designation Date: / / ❑CBRS 0 OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) Cl. Building elevations are based on: ❑Construction Drawings* 0 Building Under Construction* (]Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations-Zones A1-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/A0.Complete Items C2.a-h below according to the building diagram specified in Item A7.In Puerto Rico only,enter meters. Benchmark Utilized:RM-34 Vertical Datum:NGVD 1929 Indicate elevation datum used for the elevations in items a)through h)below. ❑x NGVD 1929 0 NAVD 1988 0 Other/Source: Datum used for building elevations must be the same as that used for the BFE. Check the measurement used. a) Top of bottom floor(including basement,crawlspace,or enclosure floor) 8 9 ❑x feet 0 meters b) Top of the next higher floor na 0 feet 0 meters c) Bottom of the lowest horizontal structural member(V Zones only) na ❑feet 0 meters d) Attached garage(top of slab) na ❑feet 0 meters e) Lowest elevation of machinery or equipment servicing the building 11 9 feet 0 meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) 7.7 ❑x feet ❑meters g) Highest adjacent(finished)grade next to building(HAG) 8 3 ❑x feet 0 meters h) Lowest adjacent grade at lowest elevation of deck or stairs,including 7.7 I feet 0 meters structural support 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 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. - O. FL FF ❑Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a ,y 0 Check here if attachments. licensed land surveyor? ❑Yes 0 No O� LpE `;'pNSED `;'pCertifier's Name License Number rt PR ES' ft7NAL Roger Dean Fleenor LS 7276 _ Title CompanyName Owner Roger ean Fleenor LPLS LLC * Sl�� OR Address City State ZIP Code No. 7276 PO Box 383414 �C�/ Waikoloa HI 96738 Signature / Date 9-6-2013 Telephone 808-989-2640 AWA II, V`' FEMA Form 086-0-33(7/12) See reverse side for continuation. Replaces all previous editions.