FEMA-EC991129FEDERAL ~EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067:b077
NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002
ELEVATION CERTIFICATE
Important: Read the instructions on pa~les I - 7.
s~CTIoN A - PROPER'FY OWNER INFOI~M,~TION For Insurance Company Use:
BU LDING OWNER'S NAME PolicY Number
j LDING~STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
STATE ZIP CODE
PROPERTY DESCRIPTION (Lot and Bloc~ Numbers, Tax Parcel Number, Legal Description, etc.)
BUILDING USE (e.g., Residential, Non*residential, Addition, Accessory, etc. Use Comments section if necessary.)
LATITUDE/LONGITUDE (OPTIONAL)
5° - f~' - f~.fh~ or ffllL.:'.:'.T.::°)
HORIZONTAL DATUM:
J__J NAD 1927 [--I NAD 1983
SOURCE: ~1GPS (Type):.
I~1 USGS Quad Map I_1 Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER I B2. COUNTY NAME I B3. STATE
B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX J B7. FIRM PANEL B8. FLOOD B9. BASE FLOOD ELEVATION(S)
NUMBER DATE | EFFECTIVE/REVISED DATE ZONE(S) (Zone AO, use depth of flooding)
B10 nd cate the source of the Base Food Elevation (BFE) data or base flood Uepth entered in Bg.
I_1 FIS Profile L-J FIRM J~ Community Determined I.~1 Other (Describe):
Bll. Indicate the elevation datum used for J~eBFE in B9: j~'NGVD 1929 I.~1 NAVD 1988 [__] Other (Describe): '
B 12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I_1 Yes ~J' No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: I__lConstruction Drawings* I~J, Building Under Construction* L_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, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/Al-A30, AR/AH, ARJAO
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 Conversion/Comments
Elevation reference mark used Does the elevation reference mark used a
CI a) Top of bottom floor (including basement or enclosure)
r~ b) Top of next higher floor . __ ft.(m)
CI c) Bottom of lowest horizontal structural member (V zones only) . __ ft.(m)
I;I d) Attached garage (top of slab) . __ tt.(m)
I;i e) Lowest elevation of machinery and/or equipment
servicing the building . __ ft.(m)
Q f) Lowest adjacent grade (LAG)
13 g) Highest adjacent grade (HAG) ~-~ 5; . ~.~ fl.(m)
I~ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade ;3
CI i) Total area of all permanent openings (flood vents) in C3h sq. in. (sq. cra)
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 ce~fy 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 imp#sonment under 18 U.S. Code, Sec~on 1001.
CERTIFIER'S NAMF~
TIT~,~.,~ ~_..j~_
ADDRESS
75c~ '-P~,~t~=,~, ~t~..
SIGNATURE
LICENSE NUMBER
Yes I_l No
CO_~PANY NAME
DA'I~-- Z~ -- q¢:~
TELEPHONE
Y77_-
FEMA Form 81-31, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In these spaces, copy the corresponding information from Section ~. For Insurance Company Use:
BUILDING S'~REET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number
CITY STATE ZIP COB; Corn~nY NAIC Numar
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
LI Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AD AND ZONE A (WITHOUT BFE)
For Zone AD and Zone A (without SFE), complete Items E1 through E4. If the ElevaEon 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 ~)0181 ~1 ft.(~) I I lin.(cm) L~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 b) of the building is
L~L_J ff.(m) I I lin.(crn) above the highest adjacent grade.
E4. For Zone AD only: If no tiood depth number is available, is the top of the bottom floor elevated in accordance with the community's
floodplain management ordinance? LI Yes I~1 No L_l 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 A, B, and E for Zone A (without a FEM^-issued or
community-issued BFE) or Zone AD must sign hem.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZiP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
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~1 The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor,
engineer, or archite~ 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. LI A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or
Zone ~O.
G3. I-/.i The follow!ng"infOrmatiOn (Items G4-G9) is provided for community floodplain management purposes.
IG4. PERMIT NUMBER I G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPMANCE/OCCUPANCY
I SSUED
G7. This Iptermit has,been'iSSued for: [~1 New Construction L_I Substantial Improvement
GB. Elevation of a~built lowest floor (including basement) of the building is: _ ft.(m) Datum:
G9. BFE or (in Zohe AD) depth of flooding at the building site is: . __ ft.(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
I--I Check here if attachments
FEMA Form 81-31, AUG 99 REPLACES ALL PREVIOUS EDITIONS