FEMA-EC030122F !RAL EMERGENCY MANAGEMENT AG CY
NATIONAL FLOOD INSURANCE PROGRAi~I
O.M.B. No. 3067-0077
Expires July 31, 2002
ELEVATION CERTIFICATE
mpelrtant: Read the instructions o, pa~les I - 7. · -.~ ..: ~,.
SECTION A - PROPERTY OWNER 11~ISORMATION For Insurance Company Use:
BUILDING OWNER'S NAME Policy Numar
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
CITY STATE
PROPERTY DESCRIPTION (Lot and Block 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) HORIZONTAL DATUM: SOURCE: I~1GPS (Type):
ZIP CODE
I~AD 1927 L._l NAD 1983 USGS Quad Map I.~1 Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
lB1. NFIP COMMUNITY NAME & COMMUNITY NUMBER B2. COUNTY NAME B3. STATE
B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL
ZONE(~..,NUMBER DATE EFFECTIVE/REVISED DATE
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
I_1 FIS Profile I,~I..FIRM I_.J Community Determined I~ Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: I,~L~GVD 1929 I_1 NAVD 1988 I__l Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I__1 Yes
Designation Date:
B9. BASE FLOOD ELEVATION(S)
Zone AO, use_depth of flooding)
C1.
C2.
C3.
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
Building elevations are based on: L_lConstruction Drawings* I~,LB. uilding Under Construction* L._lFinished Construction
A new Elevation Certificate will be required when construction of the building is complete.
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.)
Elevations - Zones Al-A30, AE, AH, A (with BFE), VE, Vl-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~)._l..~ Conversion/Comments ~ ~j I{~' ~'
Elevation reference mark used ~ 4-~B.'~ Does the elevation reference mark used appear on the FIRM? I~ Yes I.~No
C} a) Top of bottom floor (including basement or enclosure) ~ .
1~ b) Top of next higher floor ,~J~- ft.(m)
c) Bottom of lowest horizontal structural member (V zones only) kJ~- ft.(m)
d) Attached garage (top of slab) ~Jr- · ft.(m)
U.I~
C} e) Lowest elevation of machinery and/or equipment ,_-
servicing the building ~t~ . ft.(m)
C} f) Lowest adjacent grade (LAG) ~ .Z~--
g) Highest adjacent grade (HAG) _R'~ ~ .
0 h) No. of permanent openings (flood vents) within I ft. above adjacent grade
i) Total area of all permanent openings (flood vents) in C3h ~-' sq~ i-n. (sq. cm)
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
TITLE
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 ava#able.
I understand that any false statement may be punishable by fine orimpdsonment under 18 U.S. Code, Section 1001.
L,CE.SE .UMBER
COMPAN~y ~~
C I~;f~;M.a~l~~ STAT,.~ ZIP CODE ,../~)~
DATEoi__Z.Z...O. TELEPHONE Tz--
FEMA Form 8~1~1, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In these spaces, copy the c~,, ,esponding information from Section A.
ZIP CODE I CompanyP°licyF°rInsuranCeNumberNAicCOmpanYNumber
Use:
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX ,NO.
CITY STATE
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
1_1 c' ec <attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A~{WI'~J~U..T~, F~E)
For Zone AO artd ~.one A (without BFE), complete Items E1 through E4. If the Elevation Certificate.is intended for use as supporting
information for ~ [.'OMA 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~lml ft.(m) L_L._Jin.(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) ~3f the building is
L_I_I ft.(m) I=_l__lin.(cm) above the h!ghest adjacent grade.
E4. For Zone AO only:' If ao flood depth htlm. ber is available~ls'the t(~l~ {)¥ t. he b.(~t, on!!.~r elieval;~!, in~.accorda~3e with the '.c~,mmunity~. ~ ,
floodplain mana~lement ordinance? I_1 Yes L_I No L=,.,I 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 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.. ,0r~n~ .n~..e~to,. a..d..rninist.er t. he corn?, u. n.i[y-~s floodplain management ordinanoe .,ca, .rt co,mp!ete
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s~and~i.g.n belg. w...
Gl. Iml The information in Section C was taken from. oth .e~documentation that has been signed'and eml~o~ased by a licensed surveyor,
engineer, or architect who is authorized by state ~/oCal law to certify elevation information. (Indicate the source and date of the
elevation data in the Comments area below.)
G2. I_1A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or
Zone AO.
3. I~1 The following information (Items G4-G9) is provide~l ~'or community floodplain management purposes.
ISSUED
G7. ThiS'permit has been issued for: LI New Construction LI Substantial Improvement
G8. Eleva{i0~ of as-built lowest floor (including basement) of the building is: ft.(m) Datum:
G9. 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
Check Item if attachments
FEMA Form 81-31, AUG 99 REPLACES ALL PREVIOUS EDITIONS