FEMA-EC020402FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM'
ELEVATION 'CERTIFICATE
O.M.B. No. 3067-0077
Expires July 31, 2002,
Important: Read the inst,r,uc, tions on pages I - 7.
SECTION A - PROPERTY OWNER INFORMATION
BUILDING OWNER'S NAME IFor
Insurance Company Use:
Policy Number
ComPany NAIC NumberBUILDINGSTREETADDRESS (Including Apt.~Uit, Suite, and/or Bldg. No.) OR P·O· ROUTE AND BOX NO.
CITY STATE ZIP CODE
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
BUILDING USE (e.g., Rsaidential, Non-reaidential, Addition, Acceaao~j, etc. Uae Comments aection if cecesaary.)
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: L_l GF$ (Type):
t' - f~.##' or #~.::::::.':.?") I,~..NAD 1927 I--I NAD 1983 LI USGS Quad Map
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
lB1. NFIP COMMUNITY NAME & COMMUNITY NUMBER I B2. COUNTY NAME lB3. STATE
B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7· FIRM PANEL B8. FLOOD
NUMBER DATE , EFFECTIVEJREVISED DATE ,~ONE2~-
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Bg.
Iii FIS Profile ,~FIRM L_l Community Determined III Other (Describe):
Bll. Indicate the elevation datum used for the BFE in B9: [~LNGVD 1929 I.iJ NAVD 1988 LiI Other (Describe):
B12. Is the building located in a Coastal_Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? III Yes
Designation Date:
B9. BASE FLOOD ELEVATION(S)
Zone AC, use depth of flooding)
Ib~l_No
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: I~lConstruction Drawings* IxY3~uilding Under Construction* L~JFinished Construction
A new Elevation Certificate will be required when construction of the building is complete·
C2. Building Diagram Number I (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, Vl-V30, V (with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AH, AR/AC
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~..t]~') IRT.~ Conversion/Comments
Elevation reference mark used ."~ (~::~(~ Does the elevation raferense mark used appear on the FIRM? ~ Yes LI No
I~1 a) Top of bottom floor (including basement or enclosure) 'si fl'(') r1:3 b) Top of next higher floor ~J~- ft.(m)
D c) Bottom of lowest hodzontal structural member (V zones only) ,~, ft~m~ ~/ ~'~:'G~S.T~,~.".~, /
Q d) Attached garage (top of slab) ~'Jr' ft.(m) ~/ · .' ~ - "./\"i, /
1 e) Lowest elevation of machinery and/or equipment l]~, ~..
servicing the building ,,,~,ml E
Q 0 Lowest adjacent grade (LAG) . T/--ft.(.=t
g) Highest adjacent grade (HAG) ft ('")
1 h) No. of permanent openings (flood vents) within I ft. above adjacent grade NI~' :3 / · ~J _,,.*~,~.w~,.~/i/'
1 i) Total area of all permanent openings (flood vents) in C3h jJ ~ sq. in. (sq. cml
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 informMion 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.
TITLE
ADDRESS_ ,~ . . '~
SIGNATU~ ~,
LICENSE NUMBER~:~.~ I
z,P coDE '
TSo,S
DATE TELEPHONE
SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPO?T~,NT: In these spaces, copy the corresponding informafioo fro,m.Section A. I For !nsurance Company Use:
EUILDING STREET ADDRESS (Inciuding Apt., Unit, Suite, and/or Bldg. No.) OR.P.O. ROUTE AND BOX NO. I Policy Number
013~' STATE ZIP CODE I Company NAIC Number
I
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION ((~ONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
COMMENTS
I.~ Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AC AND .Z?. ,NE A, 0NITHOUT BFE)
For Zone AC ~nd Zo.ne A (without BFE), complete Items E1 thraugh E4. If the Elevation Cer~ificate is intended for use as supporting
infonwation for a LOMA 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 LI_I ft.(m) LLlin.(cm) LI above or LI 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 I~) of the building is
LLi ft,(m) I__Llin,(cm) above the highest adjacent grade.
E4. ForZoneA(~ only: Ifnoflood depth-.nu~lberis available~i~the top ofthe b~ttomltbor e[evate~ in accordanca with the community's
floodplain management ordinance? LI Yes LI No LI Unknown. The local official must certify this information in Section G.
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICAT!ON
The pmpe ~r~y 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 AC must sign hera.
PROPERTY OWNER'S OR OVVNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS *CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
I_1 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 c~n complete
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign b~low.
Gl. L_l The information in Section C was ta~,en from oth~ documentation that has been signed and embossed by a licensed surveyor,
engineer, or architect who is authorized by state or lo.cai law to certify elevation information. (Indicate the source and date of the
elevation data in the Comments area below.)
G2. E._I A community official completed Section E for a buildihg located in Zone A (without a FEMA-issued or community-issued BFE) or
Zone AC.
G3. I__l The following information (Items G4-G9) is provided f?r community floodplain management purposes.
G7. This permit has been issued for: L~I New Construction I~l Substantial Improvement
G8. Elevation of as-built lowest floor (including basement) of the building is:
Gg. BFE or (in Zone AG) depth of flooding at the building site ia:
ft.(m) Datum:
ft.(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
I_l Check here if a,ttachments
FEMA Form 81-31, AUG 99 REPLACES ALL PREVIOUS EDITIONS