FEMA-EC010226FEDERAL EMERGENCY~ MANAGEMENT AGENCY
N,AT. ION, AL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
O.M.B. NO: 306¢-0~)77
Expires July 31, 2002
Important: Read the instructions on pa~les I - 7.
SECTION A - PROPERTY OWNER INFORMATION
BUILDING OWNER'S NAME IFor
InSurance Company Use:
Policy Num~r
comPanY NAIC NumberBUILDINGSTREETADDRi~SS_(Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
CITY STATE
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, et.c.)~
BUILDING USE (e.~.._ResidentiaL.~lon-residential, Addition, Accessory, etc. Use Comments section if necessary.)
Z.~'~5 t~ ~---~-rJ ~, L...
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: I~1GPS (Type):.
f~o_ #~,_ ~.ffl~, or ~Wk;;5.-'U:5°) LI NAD 1927 I__1 NAD 1983 [~1 USGS Quad Map LI Other:
ZIP CODE
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER B2. COUNTY NAME B3. STATE
B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRI~ PANEL I B8. FLOOD
NUMBER DATE EFFECTIVE/REVISED DATE[ ZONE.(S)
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
LI FIS Profile gl FIRM I~ Community Determined I~ Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: LI NGVD 1929 I__1 NAVD 1988 L_J Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? El Yes
Designation Date:
I
B9. BASE FLOOD ELEVATION(S)
Zone AO, u_se depth of flooding)
I~No
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LJConstruction Drawings* [~:3Building Under Construction* I~Finished 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 Al-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/Al-A30, AR/AH, AR/AO
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 ~ ~,J~,~\~es the elevation reference mark used on th~lYes I~Noappear
El b) ft.(m) ~
I~ c) ft.(m) g~J~ ?"_~"__'_ ...~....:T.~",,,~ IC~ d) ft.(m) ~=g~'~'~%L~Nbil:e J I
ft.(m)
f) Lowest adjacent grade (LAG) ~.~'0 ~ . 17.. ff.(e~)ce
Dg) Highestadjacentgrade(HAG) .~'O~ .~,ft.(~ ~ I ~I~ h) No. of permanent openings (flood vents) within I ft. above adjacent grade '.3
i) Total area of all permanent openings (flood vents) in C3h sq. in. (sq. cm)
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
Top of bottom floor (including basement or enclosure)
Top of next higher floor
Bottom of lowest horizontal structural member (V zones only)
Attached garage (top of slab)
Lowest elevation of machinery and/or equipment
servicing the building
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 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, Section 1001.
CER~T.~IER'S NAME . ~ , LICENSE NUMBER
SIG~TURE ~ ~ DATE TELEPHONE
FEMA Form 81 REPLACES ALL PREVIOUS EDITIONS
IMPORT'Al{IT: In'these spaces, copy the corresponding information from Section A. For Insurance Company Llse:
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE A,ND BOX NO. Policy Number
CITY STATE ZIP CODE Company NAIC Number
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for(l) community official, (2) insurance agent/company, and (3) building owner.
COMMENTS
I_1 Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A 0NITHOUT BFE)
For Zone AO and Zone A (without BFE), complete Items E1 through E4. If the Elevation Certificate is intended foruse as supporting
information fora LOMA or LOMR-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 I~L_l ft.(m) L_l~lin.(cm) I~1 above or L_.l 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
I_1__1 ft.(m) LL_lin.(cm) above the highest adjacent grade.
E4. For Zone AO only: If no flood depth number is available/is the top of the bottom floor elevated in accordance with the community's
floodplain management ordinance? I_1 Yes [,=,1 No I~1 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 FEMA-issued or
community-issued BFE) or Zone AO must sign here.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S 'NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
I 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.
G~.~, ' '" ' ' nS~og~medat~onnd. ~dthbeY sao:~TdSdUaT;yo~rt
G2. L-I Ac0~munityi~ffici~l"~pleted Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or
Zor~ AO: ". ........ :,~, ?~
G3. __l'.,.'l'l~e. ~°liOWing.~f~atj,o~,(It~ms G4-Gg)is provided for community floodplain management purposes.
G4. PER~,TNUMBER , i, GS. DATE PERMIT ISSUEO [ G6. OATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
ISSU£D
G7.This p~h~it.~.~a:,b~en is~tl~for: L~[ New Construction I__[ Substantial Improvement
G8. Elevation of aSeb~.'lHo~est floor (including basement) of the building is: ft.(m) Datum:
Gg. BFE or (in Zone AO) depth of flooding at the building site is: ft.(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
I__[ Check here if attachments
FEMA Form 81-31, AUG 99 REPLACES ALL PREVIOUS EDITIONS