FEMA-EC960301 (2)o.M.B.'NO. 3067-0077
ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTION: Use of this certificate does not provide a waiver of lhe flood insurance purchase requirement. This form is used only to
provide elevalion information necessary Io ensure compliance with applicable communily floodplain management ordinances,
delermine the proper insurance premium tale, and/or to support a request for a Letler of Map Amendment or Revision (LOMA or LOMR).
Instructions for completing lhis form can be found on the following pages.
SECTION A PROPERTY INFORMATION
BUILDING OWNER'S NAME
Per,",,/ s JFOR~
INSURANCE COMPANY USE
POLICY NUMBER
STREET ADDRESS (Including Apt., Unit, Suile and/or Bldg. Number) OR ~.O. ROUTE AND BOX NUMBER
OTHER DESCRIPTION (Lot and Block Numbers, etc.) /,,"~.
STATE ZiP CODE
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provide the following from the proper FIRM (See Instructions):
7. Indicate the elevation datum system used on the FIRM for Base Flood Elevations (BFE): ~_J NGVD '29 [_~ Other (describe on back)
8. For Zones A or V, where no BFE is provided on lhe FIRM, and the communily has established a BFE for this building site, indicate
the community's BFE: !._LJ_J_]_J .~_~ feet NGVD (or other FIRM dalum-see Section 13, Item 7).
SECTION C BUILDING ELEVATION INFORMATION
1. Using the Elevation Certificale Inslructions, indicate the diagram number from the diagrams found on Pages 5 and 6 thai best
describes the subject building's reference level ~'_
2(a). FIRM Zones A1-A30, AR, AH, and A (with BFE). The top of the reference level lloor from the selected diagram is at an elevation
of L.~_~_L~]_51 .[~ feet NGVD (or other FIRM datum-see Section B, Item 7).
b). FIRM Zones V1-V30, VE, and V (wilh BFE). The botlom of the lowest horizontal slruclural member of the reference level from
the selected diagram, is at an elevation of U_. ~___~ __I .!_ I feet NGVD (or other FIRM dalum-see Section B, Ilem 7).
c). FIRM Zone A (without BFE). The floor used as the reference level from the selected diagram is I I I.[_~ teat above [] or
below [] (check one) the highest grade adjacent to the building.
d). FIRM Zone AC. The floor used as lhe reference level from Ihe selecled diagram is ! I !.~_J feet above [~ or below [] (check
one) the highest grade adjacent lo the building. If no flood depth number is available, is lhe building's lowest floor (reference
level) elevated in accordance with the community's floodplain management ordinance? [] Yes [] No [] Unknown
3. Indicate the elevation datum syslem used in delermining the above reference level elevations: I~'NGVD '29 [] Other (describe
under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is different than that used on
the FIRM [see Section B, Item 7], then convert the elevations to the datum system used on the FIRM and show the conversion
equation under Comments on Page 2.)
4. Elevation reference mark used appears on FIRM: [] Yes [~No (See Instructions on Page 4)
5. The reference level elevation is based on: ~-/r"actual construction _~_ conslruction drawings
NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which
case this certificate will only be valid for the building during the course of construction. A post-construction Elevation Certificate
will be required once construction is complete.)
6. The elevation of lhe lowest grade immedialely adjacent lo the building is: [_ 1 r~l~J ~1. L_~ .feet NGVD (or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
1. If lhe community official responsible for verifying building elevations specifies lhal Ihe reference level indicated in Section C, Ilem 1
is not the "lowest floor" as defined in the communily's floodplain management ordinance, the elevation of the building's "lowest
floor" as defined by the ordinance is: L_~__~ t ! _1 .!_! feel NGVD (or other FIRM dalum-see Section B, Item 7).
2. Date of the slart of construction or substantial improvement
FEMA Form 81-31, MAY 93 REFt. ACES ALL PREVIOUS EDItiONS SEE REVERSE SIDE FOR CON11~A11ON