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IMPORT ANT: In these spaces, copy the corresponding information from Section A For Insurance Company Use: BUILDING STREET ADDRESS (Induding Apt, Un~ Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number 5th STREET CITY STATE ZIP CODE Company NAIC Number ZEPHRYHILLS FL 33541 SECTION D. SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenVc:ompany, and (3) building owner. COMMENTS o 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 ttems E1 through E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F, Section C must be completed. E1. Building Diagrcm 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 Oncluding basement or enclosure) of the building is _ ft.(m) _in,(an) 0 above or 0 bela.Y (check one) the highest CKljocent grade. (Use natural grOOe, if avalable). E3. For Building Diagams &a with openings (see page 7), the next higherfloor or aElVlied floor (elevation b) of the building is _ ft.(m) _in.(an) above the highest adjocent grOOe. Complete items C3.h and C3.i on front of form. E4. The top of the platform ct mcd1ineIY cn:IIor equipment servicing the building is _ ft.(m) _in.(an) 0 above or 0 below (check one) the highest adjocent grade. (Use natural grade, if avalable). E5. For Zone AO only: If no fIcxxl depIh number is availctJle, is the top of the bottom floor elevated in ac:cordaral with the community's floodplain management ordinance? o Yes 0 No 0 Unknown. The local official must certify this information in Section G. SECTION F . PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property 0Nl1ef" or C7M1eI's authorized representative who compIeles Sections A, B, C (Items C3.h and C3.i only), and E for Zone A (without a FEMA-issued or community- issued BFE) or Zone AO must sign here. The statements in Sections A, 8, G and E are coned to the best of my knowledge. PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE COMMENTS o Check here if attachments SECTION G. COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floOOplcin management ordinanc:e ca1 complete Sections A, B, C (or E), and G of this Elevation Certificate. eompete the appIiccilIe ilem(s) and sign below. G1. 0 The infoonation in Section C was taken from other doo.Jmentation that has been signed and embossed by a licensed surveyor, engineer, or architect who is authoozed by state or Ioca: law to certify elevation information. (Indicate the source and date of the elevciion data in the Comments area below.) G2. D A community official completed Section E for a building located in Zone A (without a FEMA-issued or c:ommunity-issued BFE) or Zone AG. G3. 0 The following information (Items G4-G9) is provided for community floodplain management purposes. G4. PERMrr NUMBER G5. DATE PERMrr ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7. This pemlit has been issued for. 0 New Construction 0 Substaltiallmprovement G8. Elevation of as-buitt Iowesl floor (including basement) of the building is: G9. BFE or (in Zone AO) depIh of flooding at the building site is: LOCAL OFFICIAL'S NAME COMMUNITY NAME SIGNATURE COMMENTS _._fl.(m) _._ft.(m) Datum: Datum: TITLE TELEPHONE DATE FEMA Form 81-31, January 2003 o Check here if attachments Replaces all previous editions