FEMA-EC040204FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Iin " rtant: Read the instracilofitiori a es 1 - 7,
SECTION A" PROPERTY OWNER INFORMATION
BUILDING OWNER'S NAME
BUI~G STREET ADDRESS (InCIUd~Unit, Suite, andlor Bldg, No,) OR P,O, ROUTE AND BOX NO,
CITY STATE
Co ""t9Ci\S
PROPE TY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc,)
BUILDING SE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use a Comments area, if necessary.)
b9J'tIA.-L
LATITUD~ILONG~TUDE (OPTIONAL) HORiZONTAL DATUM: SOURCE: I_I GPS (Type):If-## -##,## or ##,#II##if') ~NAD1927 I_I NAD 1983
I_I USGS Quad Map
O.M,B. No, 3067-0077
Expires December 31, 2005
iI ,.., . ';. ...\.. . , .'.
ZIP CODE
1&01
vo)'~l>ScL ~ So ~.
SECTION B " FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
I>'LOther 1=f...A
B1, NFIP COMMUNiTY NAME & COMMUNITY NUMBER
c.oPP
B2, COUNTY NAME
B4, MAP AND PANEL B5, SUFFIX B6, FIRM INDEX B7, FIRM PANEL B8, FLOOD
NUMBER ..... DATE EFFECTIVE/REVISED DATE ZONE(S)
48\1 ~e..o\I5S oj Oe..,.. X
B10, Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
I_I FIS Profile I#IRM 1-' Community Determined I_I Other (Describe):
B11.lndicatethe etevation datum used for the BFE in B9: I~GVD 1929 I_I NAVD 1988 1-' Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?
Designation Date:
b ;;;;-,.)TD~
B9, BASE FLOOD ELEVATION(S)
Zone AO, use depth ot flooding)
oUo.
I_I Yes I~o
SECTION C. BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: I_I Construction Drawings' ~i1ding Under Construction' I_I Finished 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 A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA, AR/AE, ARlA1-A30, ARlAH, ARlAO
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 tJ&Jj) !'1V! Conversion/Comments '8.u. "Roal. Den ~ Elol<'ILl....Al_ u..firJur;;"!lI5tE.V
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? I_I Yes l$No
CI a) Top of bottom floor (including basement or enclosure) ~. jSft,(.) m
CI b) Top of next higher floor ~,~'..) <Il
CI c) Bottom of lowest horizontal structural member 01 zones only) alA-:... ' ft,(m) ~ ~
CI d) Attached garage (top of slab) ~ ,1;f ft,(1t) ~ ~
CI e) Lowest elevation of machinery andlor equipment ~ ~
servicing the building (Describe in a Comments area.) 4S'l, Ire ft.(..) ~ ~
CI f) Lowest adjacent (finished) grade (LAG) 4P.A '. ft.(.) :i,~
CI g) Highest adjacent (finished) grade (HAG) 4-9t ,J.uft.(.) ~ <Il
CI h) No, of permanent openings (flood vents) within 1 ft. above adjacent grade tJI... ~
o i) Total area of all permanent openings (flood vents) in C3,h ~..... sq. in. (sq. em)
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 fhat 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 V,S, Code, Section 1001,
FIER'S NA~ LICENSE NUMBER
ql
TIT~~ CO~~ t<t-It.~
AD~E S C I..e:k( TATE ZIP 9f~~
SIGNATU DATE TELEPHONE
FEMA Form 81-31, January 2003 See reverse side for continuation.Replaces all previOUS editions
IMPORTANT: In these spaces, copy the corresponding information from Section A.
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg, No,) OR P,O, ROUTE AND BOX NO,
V .0
CITY STATE ZIP CODE
COP ~As -, 4111114111111111111
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
0\ v.rt"~'r'~ j'.
t..V'~J;J
1'1, I ':'. "1'1?(<<u(~..If. .~- .~
tfto. ("S.... ..... &:'-;'\) -:,-, rA11..&:. /::9" k.' I~CRf,Ck here.Ji*hm~"'",
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (Vl!ITH UT ~F
For Zone AO and Zone A (without BFE), complete Items E1, through E5. If the Elevation Certificate is intended for use as's 0 In
information for a LOMA or LOMR-F, Section C must be completed, '
E1, Building'~rain Number ~ (Select the building diagram most similar to the buitding 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 (inctuding basement or enclosure) of the building is 1_1_1 ft, (m) 1_1_1 in. (cm) LI above or I_I below
check one) the highest adjacent grade. (Use natural grade, if available,)
E3. For Building DiallJ1lrll,li!,6;f\with openings (SEle<Pl!ge j),lhe next !>ij}I\el fiII\lr pr elevated floor (elevation b) Qf~~"I~ing is :': .: ,-.
1_1_1 ft, (m) 1_1_lin, (cm) above the highest adjacent grade. Comptete l!ems C3,h and C3.i on front of form,
E4. The top of the platform of machinery and/or equipment servicing the building is 1_1_1 ft. (m) 1_1_1 in. (cm) I_I above or I_I beiow
check one) the hi~I1Il,~t adjacent grade, (~se natural,jlr~~~df avail.able,,~';._ '!'-'..'(; ~ ",~' ':,~ , ~<:?I')"'<: . "..;.
ES, For Zone AO only: 1f~0 flood depth number IS available, IS the tol> of the bottom floor elevat~ifi1accordance With the community's
floodplain management ordinance? I I Yes I I No I I 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 />:, B, C (Items C3,h and C3.i only), and E for Zone A
without 8 F'EMA-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 knowledge.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE
COMMENTS
DATE TELEPHONE
I I Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The tocal official. .is:>9~rizj~by law or~~ni':lpoi'drniniJ(fr th~c~/IlMtY's fl_lain management ordinanc;g-~~c~"
Section.s A, B, C (or E), and G'ot this Elevation Certificate, Complete the applicable item(s) and sign below.
G1, I_I The information in Section C was tak$l' f~other'd!lcumentation that has been signed and embossed by a licensed surveyor,
engineer, or architect who is authori~d ~fjate ?r 1~llaw to certify elevation information. (Indicate the source and date of the
elevation data in the Comments areaoelow,) " .'.
G2. 1-' A community official completed Section E wra buil,<!ir~ located in Zone A (without a FEMA.issued or community-issued BFE) or
ZoneAO. - 1", ~'. "
G3. !-' The following information (Items G4-G9) is ~ovi<t'i ,for community floodplain management purposes.
G4~flERMIT NUMBER G5, DATE PE"lljj~D G6, DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
I, . ...
t" ISSUED
G7. This permit has been issued for: 1-' ew Co~s,tr~c~on I_I Substantial I mprovement
Ga. Elevation bf.a~-built lowest floor (including basemlr1!) of the buildin~ is:
G9. BFE or (in Zo"e AO) depth of flooding at the building site is: ." ,
ft. (m) Datum:
ft, (m) Datum:
LOCAL OFFICIAL'S NAME
COMMUNITY NAME
TITLE
TELEPHONE
SIGNATURE DATE
COMMENTS
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a ,J.4 ""..1: ..~t.~
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0 i. J."lo ~J-')1o~A,:..~'(4.'...4 '"lt'~f'
j.... ~.I I Check hw:.ej/ at~ments
Replaces all previous editionsFEMAForm81-31, January 2003