FEMA-EC020722BUILDING OWNER'S NAME
FEDERAL EMERGENCY MANAGEMENT AGENCY
NA?IONAL FL .OOO INSURANCE PROGRAM
ELEVATION CERTIFICATE. · ·
I .mp?tant: Read the Instr,_J_ ~t~:~l~ on pases I - 7.
SECTION A - PROPERT~ OWNER INFORMATION
lO.MB. No. 3067-0077
Expires July 31, 2002
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or BIdg· No.) OR P.O. ROUTE AND BOX NO.
CITY STATE
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
BUI],,DING USE (e:§., Residential, Non-residential:Addition, A__ _ ~ory, etc. Use Comments section if
LATiTUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: I I GPS (Type):
ffl~'-#~'-f~.~t' or ~.:7..:'.'.:.<) 1~1927 I INAD1983 I IUSGSOuadMap
ZIP CODE
SECTION B . FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1.~__.4~ [=~~I_NFIPCOMMUNITY~__ NAME&COMMUNITY,~¥~I~i ,"'~O
NUMBER [ B~NAME I B3.~
B4. MAP AND PANEL BS. SUFFIX B6. FIRM INDEX B7. FIRM PANEL TEI B8. FLOOD B9. BASE FLOOD ELEVATION(S)
NUMBER DATE EFFECTIVE/REVISED DA ZOj~) (Zone AO, use depth of flooding)
10. Indicate the source of the Base Flood Elevation (BFE) dat~-or b~se flood depth'entered in B9.
I I FIS Profile ~,FIRM I I Community Determined I I Other (Deschbe):
BI 1. Indicate the elevation datum used for the BFE in B9: I~ NGVD 1929 L_l NArD 1988 L_l Other (Describe):
B12. Is the building located in a Coastal Ba~ier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I I Yes I~ No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
Cl. Building elevations are based on: L_~Construction Drawings* I~uilding Under Construction* L._lFinished
A new Eldvation Cedificate 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. Eldvations - Zones A1 -A30, AE, AH, A (with BFE), VE, VI-V30, V (with BFE), AR, AR/A, AR/AE, AR/A1 -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. Shew 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 ~ Converaion/Comments
Elevation reference mark used~ the elevation reference mark used a ~ No
n a) Top of bottom floor (inctuding besement or enclcaure) ,~_(., .~_ft.(I) ~
O b) Top of next higher fioor ~,,~, .__ft.(m)
E] c) Bottom of lowest horizontal Ml~ctural member (V zones only) ~ . __ ft.(m) ~ :~
O d) Attached garage (top of slab) j[l]~.. __ ft.(m) ~;
n e) Lowest elevation of machine~ and/or equipment
n 0 Lowest adjacent grade (LAG)
O g) Highest adjacent grade (HAG) ~ .
O h) No. of permanent openings (flood vents) within 1 ft. above adja .ca~ grade
r-t ~ Total area of ali permanent openings (flood vents) in C3h ~ sq. in. (sq. cra)
SEC'rlON 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 cat~y that the informaUon in Sections A, B, and C on this carSflcate represents my best efforts to interpret the date available.
I understand that an)/false statement may be punishable by fine or imp~fsonment under 18 U.S. Code, Section 1001.
LICENSE N U~;-'--'- ~
TELEP.ONE
ZIP CO~,jl~.~)
FEMA Form ~"~, AU~ SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In these "rn="~, copy the corresponding information from Section A.
BUILDING ST__REET ADDRESS (Includin~ Apt., U_nit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
CITY STATE ZIP CODE
IPOlicy
Number
I
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CEI~TiFICATION JCONTINUED)
Copy beth sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
COMMENTS
I;..~_J Che~l(h~l~ if atachmerits
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQU RED) FOR ZONE AO AND ZONe. 'A (W~H.INJT BFE)
For Zone ,~O, .a~...d ;~one A (without BFE), complete items E1 through E4. If the ElevaUon Ce~fica!e is intended for use es supporUng
informatl~n bY ~ LOMA or LOMb-F, Section C must be completed.
El. Building Diagram Number (Select the building diagram most similar to the building for wh~h 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 ~ ft.(m) I I lin.(cm) U above or I I below
higlr~at qdja -~' ..... J.-*. ,'check one) the cent grade. · ......., 7... "' ' ·
E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is
fl.(m) L_L_Jin.(cm) above the highest adjacent grade. .,
E4 For Zone AO~dy::~ltoflond depth n~lmber, sava able, hfthe,., t0~ ~l;j;te bottom fl0or · .le~t, ed in'accordanice with theco~rnuajty;$. . ;~ *
fi__OOd~l=_in mana~lement ordinance?I-IYes U NO II Unknown. The local official must cert~ this information in Section G.
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) C~-KJi~.iCATIOR
The propal.'ly owner or owner's authorized representative who completes Sections A, B, and E for Zone A (without a FEMA-iseued or
communiiy~issued BFE) or Zone AO must sign hera.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED i~i=PRE. SENTATIVE'S NAME
ADDRESS .~ClTY STATE ZIP CODE
SIGNATURE CATE TELEPHONE
COMMENTS
Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by ow or ordinance to administer the community's floodplain management ordinanes ca.n complete.
Sectiol~ A, B, C (or E), and G of this Elevation Certificate. Complete the epplicelde, iter~.~) iand.~,~ ~.ll~el,o~,,
Gl. I'1 The information in Section C was tek, eh fn3f'n other d~lcumantafion that has ~on ~ign~l ariel ~ml:k~.~,ed by a licensed surveyor,
engirl~er, or architect who is authorized b~ ~tate ~ Io~l law to certify elevation information. (Indicate the source and date of the
elevation data in the Comments area below.) ' '~ ~
G2. II A c~mmunity official completed Section E for a bU..ilding located in Zone A (without a FEMA-issued or community-issued BFE) or
Zone AO;.: -. ·
G3. I I The following ~3rmation (Items G4-Gg) is pmvid~l.for community floodplain management purposes.
JG ti.. pERMIT NUMBER I GS. DATE Pt:l,~ll ~ ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
SSUEDG7. Thispermithesbesnissuedfor: I I NewCon'if~ ~r~ctionLrJSubstantial
ImprovementG8. Elevationof ~e-buiitlowestfloor (includingbasement) ofthebufld~gis: . __ ft.(m) Datum:Gg. BFEor (inZoneAO) depthoftioodingatthebuildingsiteis: ft.(m) Datum:LOCALOFFICIAL'SNAMETITLECOMMUNITYNAMETELEPHONESIGNATUREDATECOMMENTSI--ICheckhereifattachmentsFEMAForm81-