The URL can be used to link to this page

Home My WebLink AboutElevation Certificate?DERAL EMERGENCY MANAGEMENT Ar ICY NATIONAL FLOOD INSURANCE PROGFL ,,d ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION BUILDING OWNER'S NAME Gal►E O.M.B. No. 3067-0077 j Expires July 31. 2002 For Insurance Company Use: Policy Number BUILDING STREET ADDRESS (Including Apt., Urat. Sure. and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. -t a 2,6 Pe -r- F 7 CITY Company NAIC Number Zi STATE P CODE Pm.R. b 23 PROPERTY DESCRIPTION (Lot and fiiadc Numbers, Tax Parcel NurriheJ , Legal Description, etc.) DT"r--"1-5 i3`sw b M QM 5(43 to L$1.73-4, LOT 3 BUI Non-residential. G USE (e.g., Residential, Addition. Accessory. etc. Use a Comments area, if necessary.) }•SL9 LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: ( #r - U' -*tor or ##4#A0°j f j NAD 1927 U NAD 1983 SOURCE: DS GPS (Type): M N V Lj USGS Quad Map u Other: SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION BI. NFIP COMMUNITY NAME & COMMUNITY NUMBER B2. COUNTY NAME B3. STATE 84. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL B8, FLOW B9. BASE FLOOD ELEVATIal(S) NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO, use depth offlooding) 6,2- e)Biza 05 1 8S6 B 3 3,IIS6_ A -I .0c) 810. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. FIS Profile XIFIRM LI Community Determined LI Other (Descnbe): C~ PS IAD 611. Indicate the elevation datum used for the BFE in 89: NGVD 1929 LTJ NAVD 1988 Li Other (Describe): ile14 LID R,M 2.4 B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? Lf Yes DK1 No Designation Date: SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations we based an: j, onstnuctian Drawings" L.f9uiiding Under Construction' LjFinished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number NA (Select the building diagram most similar to the building for which this certificate is being completed - see pages 6 and 7. ifno diagram actrrately represents the building, provide a sketch or photograph.) C3. Elevations — Zones A1 -A30, AE, AH, A (with BFE), VE, V7 V30, V (with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AH, AR/AO Complete Items G3.a.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 8, convert the datum to that used for the BFE. Show field measurements and datum conversion calculation. Use the space provided or the Commen area of Section D or Section G, as appropriate, to document the datum conversion. Datum t•LC*UD Conversion/Comments �1-& Elevation reference mark used (, �C"f .17- Does the elevation reference mark used appear on the FIRM? U a) Top of bottom flow (including basement or enclosure) Co 24 t . Q fk(m) Ts - CI b) Top of next higher floor . ft.(m) CI c) Bottom of lowest horizontal structural member (V zones only) ft(m) o g. Cr d) Attached garage (top of slab) ft -(m) it a ❑ e) Lowest elevation of machinery and/or equipment ti servicing the building (Describe in a Comments area.) . ft(m) £ m U f) Lowest adjacent (finished) grade (LAG) . ft(m) m m U g) Highest adjacent (finished) grade (HAG) - ft -(m) 2 ❑ h) No. of permanent openings (flood vents) within 1 ft above adjacent grade e ❑ 1) Total area of aft pennanent openings (flood vents) in C3.h sq. in. (sq. cm) Yes ILL No SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by Taw 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. / understand that an false statement ma be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. 5 NUM R C5 Lr. S .rr ED2k-4 (0 TITLE OLA -1 �E �T ADDRESS p . 0. iNa-is 63 SIGNATURE COMPANY NAME -11 Lrit4E. c-&-1 U «M g.lhie t;7 r '�2 iD & sTAGcz, LZIPC4°�2 3 DATE a,. 2.40( (0 TELEPHON 0 e 3 cot 7 FFMAA Fnrm A1.. 1 .111, (W CFF RFVFRSP SW1F FCR (:r]NTINIJATIf7N RFPtA('FS Al I PRFVU(SFJS FfITI()NS -IMPORTANT: In these spaces, copy t •orresponding information from Section A. For Insurance Company Use: BUILDING j� ADDRESS (Indudng Apt.,'Jrd Suite, and/or Bldg. No.) OR P.0 ROUTE AND BOX ,4[3. Policy Number - C1k�t.0 .t( C _ cA-L� L - FF'-" `l t- 1�,4 - CUY STATE ZIP CODE 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, 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 El. through E4. 0 the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F, Section C must be completed. El. 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 LI_i ft.(m)1-1_Iin•(cm) 1_I above or L1 below (check one) the highest adjacent grade. (Use natural grade, if available.) E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is I I I ft -(m)1 ' i lin.(cm) above the highest adjacent grade. Complete Items C3.h and C3.1 on front of form. E4. 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? L..1 Yes (,J No L...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, 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. ► e statements in Sections A, B, C, and E we correct to the best of my knowledge. PROPE=RTY OWNER'S OR OWNER'S AUTHORIZED REPRESEF1TAt1VE'S NAME (�4-J1:266-1� ADDRESS t3 CITY STATE ZIP CODE SIGNATURE LEf'�10N ia c� �� a COMMENTS Li 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, EI, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. G 1. 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. 1J 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. 1J The following information (Items G4 -G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER GS. DATE PEPMW t$$UED a. DATE CERTIF`CATE OFCOtd1PLIANCE /OCCUPANCY ISSUED G7. This permit has been issued for LI New Construction Ll Substantial Improvement G8. Elevation of as -built lamest floor (including basement) of the building is: G9. BFE or (in Zone AO) depth of flooding et the building site is: . ft.(m)Datum: ft.(m)Datum: LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS IJ Check here if attachments FFIUA Fnrm R1 -A7 .1111 An RFPI AC!FR Al 1 PRP—ye—NM Pnmr1NS