FEMA-EC030825FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
lO.MB No. 3067-0077
Expires,July 31, 2002
Important: Read the instructions on pallas I - 7.
SECTION A - PROPERTY OWNER INFORMATION
BUILDING OWNER'S NAME
BULLDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
For Insurance company use:
Policy Number
Company NAIC Number
CITY STATE ZIP CODE
e.a, e,c.,
BUILDING USE (e.g., Residential, Non-residential, Addition, A~sso~, etc. Use Commen~ se~ion if ne~ssa~.)
LATITUDE/LONGITUDE (OPTIONAL)
o. ##,. ~#.~p or ~.~£5;;°)
HORIZONTAL ~ATUM:
NAD 1927 J~NAD 1983
SOURCE:L~t GPS (Type):
I USGS Quad Map J~LOther:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMUNITY NAME & COMMUNITYNUMBER~~ Zli--~:~ I'"'/~) IB2. cOuNTYNAME~ IB3. STATE
LB4. MAP AND PANEL BS. SUFFIX BS. FIRM INDEX B7. FIRM PANEL I B8. FLOOD B9. BASE FLOOD ELEVATION(S)
NUMBER DATE EFFECTIVE/REVISED DATE I , ZONE(S) (Zone AD, use depth of flooding)
B10, Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
I_1 FIS Profile ~L~IRM I~ Community Determined IJ Other (Describe):
Bll. Indicate the elevatio~"dat~m used for the BFE in B9: I _~J?GVD 1929 I_1 NAVD 1988 IJ Other (Describe):
B12. Is the building located in a Coastal_Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I_1 Yes I~l~No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: I~jConstruction Drawings* ~:~uilding Under Construction* I__JFinished Construction
A new Elevation Certificate will be required when construction of the building is complete.
C2. 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.)
C3. Elevations- Zones Al-A30, AE, AH, A (with BFE), VE, VI-V30, V (with BFE), AR, AR/A, AR/AE, AR/Al-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~(=,~JO {¢~'~ Conversion/Comments
Elevation reference mark usedC~)J)l:3-~ ~r)'. '~ .l~_e~}, Does the elevation reference mark used appear on the FIRM? L_.l Yes ~No
3 a) Top of bottom floor (includin~l ~asement or enclosure) ~ . ~¢~ ft.(~)
b) Top of next higher floor ~J-J~ . fl.(m)
c) Bottom of lowest horizontal structural member (V zones only) ~ .--ft.(m) ~1 J~..'~['~?'~'~"..~
d) Attached garaoe (top of slab) '~[,~r-.-,.<~> 'k L
e) Lowest elevation of machinery and/or equipment
servicing the building ~_~" . ff.(m)
f) Lowest adjacent grade (LAG) '
g) Highest adjacent grade (HAG) ~"t~X.O .O fl.(m)
h) No. of permanent openings (flood vents) within 1 lt. above adjacen, t g~de ~ ~
i) Total area of all permanent openings (flood vents) in C3h ~ sq. ~. (sq. cm)
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, B, and C on this certificate represents my best efforts to interpret the data available.
I understand that any false statement may be punishable by fine orimpdsonment under 18 U.S. Code, Section 1001.
TITLE
ADDRESS "~ ~D{::~ "~/~ ~ O~ ~.
FEMA~F-en'I~'81-31, ~,UG 99 SEE REVERSE SIDE FOR CONTINUATION
LICENSE NUMBER
c'X
Z,PCODE
W88
DATE TELEPHONE ~ ~ ~~
REP~CES ALL PREVIOUS EDITIONS
IMPORTANT: In t~he~se~s~aces, 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.
I Policy. Number
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.
COMMENTS
I__1 Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A 0NITHOUT BFE)
For Zone AO and Zone A (without BFE), complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting
information for a L OMA or L OMR-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 I__1__1 ft.(m) I~[_..Jin.(cm) L_J above or [_._1 below
check one) the highest adjacent grade.
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_1__1 ft.(m) I__[._lin.(cm) above the highest adjacent grade.
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? I_1 Yes [_.l No I_1 Unknown. The local official must certifi/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 OVVNER'S OR OVVNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
I I 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.
Gl. I__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. I~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. L_l The following information (Items G4-G9) is provided for community floodplain management purposes.
G4. PERMIT NUMBER G5. DATE PERMIT ISSUED I G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
ISSUED
G7. This permit has been issued for: I_.l New Construction L_l Substantial Improvement
G8. Elevation of as-built lowest floor (including basement) of the building is:
G9. BFE or (in Zone AO) depth of flooding at the building site is:
LOCAL OFFICIAL'S NAME TITLE
ft.(m) Datum:
ft.(m) Datum:
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
Check here if attachments
FEMA Form 81-31, AUG 99 REPLACES ALL PREVIOUS EDITIONS