FEMA-EC021218FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Important: Read the instructions on pa~les 1 - 7.
SECTION A - PROPERTY OWNER INFORMATION
BUI~IN(~ OWNER'SJ~MEd
BUILDING ST~.EET ADDJ~ESS (Inc~_ng ~pt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
O.M.B. No. 3067-0077
Expires July 31, 2002
For Insurance Company Use:
Policy Number
Company NAIC Number
c'7: opp-- I t --r×STATE
Nu. mbe[s,,T, ax, P, arcel Number, J,~gal Descriptio~.PrJ, c.)P ~.~.'I'Y Df SC R, PTI ~ ~ott..~d~ ~..k
BU. JJ.plNG U, SE,(e.g., Re, si~entia~, Non-residential, Addition, Accessory, etc. Use a Comments area, if necessary.)
LATITUDE/LONGITUDE (OPTIONAL)
o. ~,. ~.~. or f~.~........./............;o)
HORIZONTAL DATUM: SOURCE: L-I GPS (Type):.
NAD 1927 LI NAD 1983 L--I USGS Quad Map I--I Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B2. COUNTY NAME B3. STATE
B4. MAP AND PANEL I B5. SUFFIX
NUMBER I
48OI70-00t01 E
B6. FIRM INDEX
DATE
B7. FIRM PANEL
EFFECTIVE/REVISED DATE
4-- 5 -ct4
B8. FLOOD
ZONE(S)
x
BD. BASE FLOOD ELEVATION(S)
Zone AO. use depth of flooding)
B 10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in BD.
I--I Fm Profile I--I FIRM I--I Community Determined IXl Other (Describe): [..O~"1 ~ ~ - O6 ---'/,~'~' P
B11. Indicate the elevation datum used for the BFE in BD: r~l NGVD 1929 I--I NAVD 1988 L-I Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I--I Yes I~--I No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
1. Building elevations are based on: I__lConstruction Drawings* I~___lBuilding Under Construction* I__lFinished Construction
A new Elevation Certificate will be required when construction of the building is complete.
C2. Building Diagram Number J (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, Ak, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, APJA, AR/Ak, AR/Al-A30, AR/AH, AR/AO
Complete Items C3.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 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 I~ Iq~qConversion/Comme~ts ......................................
ElevatiOn reference~nark used (~ ~ _'~_~ _C__op_~J [ Does the elevation reference mark used appear on the FIRM? I--I Yes ~1 No
I;i a) Top of bottom floor (including basement or enclosure) '~' ~ ~ . _(~)~ ft.(m) -~
Q b) Top of next higher floor
QI c) Bottom of lowest horizontal structural member (V zones only)
Q d) Attached garage (top of slab)
1 e) Lowest elevation of machinery and/or equipment
servicing the building (Describe in a Comments area.)
QI f) Lowest adjacent (finished) grade (LAG)
I~ g) Highest adjacent (finished) grade (HAG)
Q h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade ........
Q i) Total area of all permanent openings (flood vents) in C3.h sq. in. (sq. cm)
ft.(m) ~)
ft.(m) ~,
ft.(m) ~
UJ
ft.(m)
ft.(m)
ft.(m)
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 or imprisonment under 18 U.S. Code, Section 1001.
l rool<c' r Dr.
FEMA Fon~ 81-31, JUL 00
COMPANY NAME ,
S- '--~C~ bill {~ ~ STATE'"~-.~Z~"'~ZIPCOD_E
SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPOI~I'ANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use:
B_~L~DI.NG S,T_REET A. DDRESS I~clu,ding Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number
r~r l~r; v~
CITY 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-I 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. If 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 I--I--I ft.(m) I__l_lin.(cm) I--I above or I--I 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) I__l__lin.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i 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 mana~lement ordinance? I--I Yes I--I No I--I Unknown. The local official must certif7 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. The statements in Sections A, B, C, and E are correct to
the best of my knowled~le.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
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--I 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 BOUrne 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. I--I 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
I ISSUED
G7. This permit has been issued for: I--I New Construction I--I Substantial Improvement
G8. Elevation of as-built lowest floor (including basement) of the building is: .... ft.(m) Datum:
G9. BFE or (in Zone AO) depth of flooding at the building site is: ft.(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
I--I Check here if attachments
FEMA Form 81-31, JUL 00 REPLACES ALL PREVIOUS EDITIONS