FEMA-EC941109ELEVATION CERTIFICATE o M ~o3o6,.oo ,
Expires May 3 I, 1993
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATrENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to
provide elevation information necessary ID ensure compliance with applicable community floodplain management ordinances, ID
determine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Revision (LOMA or LOMR).
Instructions for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION FOR INSURANCE COMPANY USE
BUILDING OWNER'S NAME POLICY NUMBER
STREET ADDRESS (Including Apt, Unit, Suite and/or Bldg Numbe0 OR PO. ROUTE AND BOX NUMBER COMPANY NAtC NUMBER
OTHER DESCRIPTION (Lol and Block Numbers, etc.)
CITY STATE ZIP CODE
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provide the following from the proper FIRM (See Instructions):
4 DATE OF FIRM INDEX 5 FIRM ZONE 6. BASE FLOOD ELEVATION
450170 OolO O I¢,,/9')/ S ,,,
7. Indicate the elevation datum system used on the FIRM for Base Flood Elevations (BFE): [~ NGVD '29 ~-~ Other (describe on back)
8. For Zones A or V, where no BFE is provided on the FIRM, and the community has established a BFE for this building site, indicate
the community's BFE:I } L J ~ J.L l feet NGVD (or other FIRM datum-see Section B, Item 7).
SECTION C BUILDING ELEVATION INFORMATION
1. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best
describes the subject building's reference level .
2Ca). FIRM Zones Al-A30, AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an elevation
of[ J ~4[~'~4~ .[~ feet NGVD (or other FIRM datum-see Section B, Item 7).
Cb). FIRM Zones V1 -V30, VE, and V (with BFE). The bottom ol the ~owest horizontal structural member of the reference level from
the selected diagram, is at an elevation of i J J [ J J.[ J feet NGVD (or other FIRM datum-see Section B, Item 7).
Cc). FIRM Zone A (without BFE). The floor used as the reference level from the selected diagram is [ J J.[ I feet above [J or
below ~ i~ (check one) the highest grade adjacent to the building.
Cd). FIRM Zone AD. The floor used as the reference level from the selected diagram ~s i .[ J.[ J feet above !~1 or below ~ i (check
one) the highest grade adjacent to the building. If no flood depth number is available, is the building's lowest floor (reference
level) elevated in accordance with the community's floodplain management ordinance? ! i Yes I i NO [ J Unknown
3. Indicate the elevation datum system used in determining 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: I J Yes ~:~ No (See Instructions on Page 4)
5. The reference level elevation is based on: L J actual construction J construction drawings ~
NOTE: Use of construction drawings is only valid if the building does not yet have the relerence 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 the lowest grade immediately adjacent to the building is: ~ ~/~,4~. ~ feet NGVD (or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
1. I1 the community official responsible for verilying building elevations specifies lhat the reference level indicated in Section C, Item 1
is not the "lowest floor" as defined in the community's floodplain management ordinance, the elevation of the building's "lowest
floor" as defined by the ordinance is: ~. I J ~ I J. i feet NGVD (or other FIRM datum-see Section B, Item 7).
2. Date of the start of construction or substantial improvement
FEMA Form 81-31~ MAY 90 REPLACES ALL PRE VIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION