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<br />~ <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NATIONAL FLOOD INSURANCE PROGRAM <br />ELEVATION CERTIFICATE <br /> <br />a.M.B. No. 3067-0077 <br />Expires July 31, 2002 <br /> <br />1m ortant: Read the instructions on a es 1 - 7. <br />SECTION A - PROPERTY OWNER INFORMATION <br /> <br />For Insurance Company Use: <br />Policy Number <br /> <br /> <br />Company NAtC Number <br /> <br />ZIP CODE <br /> <br />LATITUDE/LONGITUDE (OPTIONAL) <br />( ##0 _ ##' _ ##.##" or ##.#####0) <br /> <br />HORIZONTAL DATUM: <br />LI NAD 1927 LI NAD 1983 <br /> <br />SOURCE: I_I GPS (Type): <br />LI USGS Quad Map I_I Other: <br /> <br />SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION <br /> <br /> <br />B2. COUNTY NAME <br /> <br />84. MAP AND PANEL B5. SUFFIX B8. FLOOD <br />NUMBER G EFFECT~R~VISE DATE ZO~) <br /> <br />B 10. Indicate the source of ~ Base Flood Elevation (BF ) data or base flood Ciepth entered in B9. <br />I_I FIS Profile I,LI'FIRM I_I Community Determined 1-1 Other (Describe): <br />B 11. Indicate the elevation datum used for the BFE in B9: I~ NGVD 1929 I_I NA VD 1988 I_I Other (Describe): <br />B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? <br />Designation Date: <br /> <br /> <br />'Il6CtJ <br /> <br />B3. STATE <br /> <br />C- <br /> <br /> <br />B9. BASE FLOOD ELEVATION(S) <br />(Zone AO, us de ~ of flooding) <br /> <br /> <br />'_I Yes <br /> <br />~NO <br /> <br />SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) <br /> <br />C1. Building elevations are based on: LIConstruction Drawings. '_I Building Under Construction* Finished Construction <br />.A new Elevation Certificate will be required when construction of the building is complete. <br />C2. Building Diagram Number -'-- (Select the building diagram most similar to the building for which this certificate is being completed - see <br />pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) <br />C3. Elevations - Zones A 1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA, ARlAE, ARIA 1-A30, ARlAH, ARlAO <br />Complete Items C3a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from <br />the datum used for the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion <br />calcula#~Us~~space provided or the Comments area.of Section D or Section G, as appropriate, to document the datum conversion. <br />Datum 'IJ , Conversion/Comments <br />Elevation reference mark used Does the elevation referez mark used appear on the FIRM? I_I Yes I_I No <br />~) Top of bottom floor (including basement or enclosure) R .2. ft.(m) ~ <br />o b) Top of next higher floor . _ ft.(m) ~ <br />o c) Bottom of lowest horizontal structural member 01 zones only) . ft.(m) ~ ~ <br />- 00 <br />o d) Attached garage (top of slab) . _ ft.(m) ~-g <br />o e) Lowest elevation of machinery and/or equipment ~ ~ <br />servicing the building . _ ft.(m) ~ ~ <br />~ Lowest adjacent grade (LAG) R'6"" 0 ft.(m) :i ~ <br />) Highest adjacent grade (HAG) ~S ~ ft.(m) ~ <br />h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade ~ <br />o i) Total area of all permanent openings (flood vents) in C3h sq. in. (sq. em) <br /> <br />SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION <br /> <br />This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. <br />I certify that the information in Sections A, 8, and C on this certificate represents my best efforts to interpret the data available. <br />I understand that any false stat ment may be unishabl by fine or imprisonment under 18 U. S. Code, Section 1001. <br />CERTIFIER'S NAME ' LICENSE NUMBER <br /> <br />TITLE <br /> <br />