FEMA-EC960419ELEVATION CERTIFICATE , ExpiresMoy 3t, t996
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM . ..
ATTENTION: Use of this certificate does nol provide a waiver of the flood insurance purchase requirement. This form is used only !o
provide elevation information necessary to ensure compliance wilh applicable communily floodplain management ordinances, to
determine the proper insurance premium rate, and/or Io support a requesl for a Letler of Map Amendment or Revision (LOMA or LOMR).
Instructions for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION
IFOR
INSURANCE COMPANY USE
POLICY NUMBERBUILDINGOWNER'S NAME
STREET ADDRE~.SS (Ir~cluding Apl., Unit, SMile anj~l/or Bldg. Number) OR PO. ROUTE AND BOX NUMBER
OTHER DESCRIPTION (Lot and BI~ Numbers, elc.)
T~
STATE
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
ZIP CODE
Provide lhe following from the proper FIRM (See Instructions):
i oI7. Indicaletheelevation datumsystemusedontheFIRM
forBaseFloodElevations (BFE): ~C'~"GVD '29 [] Olher (describeonback)8. ForZonesAorV, wherenoBFEisprovidedonlheFIRM, andlhecommunilyhasestablishedaBFEforthisbuildingsite, indicatethecommunity'sBFE: I_ II ..... J _~ feetNGVD (orotherFIRMdatum-seeSectionB, Item7).SECTION CBUILDINGELEVATIONINFORMATION1. UsingtheElevationCertificateInstructions, indicatethediagramnumberfromthediagramsfoundonPages5and6Ihatbestdescribesthesubjectbuilding'sreferencelevel (2(a). FIRMZonesAl-A30, AE, AH, andA (with BFE). Thetopof thereferencelevelfloorfromtheselecteddiagramisatanelevationof [_ tI ¥lS*l?l.l~ feetNGVD (or other FIRMdatum-seeSectionB, Item7).b). FIRMZonesV1-V30, VE, andV (withBFE). Thebottomofthelowesthorizontalstrucluralmemberofthereferencelevelfromtheselecteddiagram, isatanelevationollIIII !.1IfeetNGVD (orotherFIRMdalum-seeSeclionB, Item7).c). FIRMZoneA (withoutBFE). ThefloorusedasthereferencelevelfromIheselecteddiagramisIII*L_~ feetabove [] orbelow [] (checkone) thehighestgradeadjacentIothebuilding.d). FIRMZoneAD. ThefloorusedasthereferencelevelfromtheselecteddiagramisIIl.L_~ feetabove [] orbelow [] (checkone) thehighestgradeadjacentIDthebuilding. Ifnoflooddepthnumberisavailable, isIhebuilding'slowestfloor (referencelevel) elevatedinaccordancewiththecommunity'sfloodplainmanagementordinance? [] Yes [] No [] Unknown3. Indicalethe elevationdatumsystem usedindeterminingtheabovereferencelevelelevations: [~NGVD '29 [] Olher (describeunderCommentsonPage2). (NOTE: Iftheelevationdatumusedinmeasuringtheelevationsis differentthanthatusedontheFIRM [seeSectionB, Item7], thenconverttheelevationstothedatumsystemusedontheFIRMandshowtheconversionequationunder CommentsonPage2.)4. ElevationreferencemarkusedappearsonFIRM: [] Yes [~*No (SeeInstruclionsonPage4)5. Thereferencelevelelevationisbasedon: [~actualconstruction [] conslrucliondrawingsNOTE: Useofconstructiondrawingsisonlyvalidifthebuildingdoesnotyethavethereferencelevelfloorinplace, inwhichcasethiscertificatewillonlybevalidforthebuildingduringthecourseofconstruction. Apost-constructionElevationCertificatewillberequiredonceconstructioniscomplete.)6. Theelevationoflhelowestgradeimmediatelyadjacenttothebuildingis: III ~ ~. ~'.fee! NGVD (or otherFIRMdalum-see SectionB, Item7).SECTIONDCOMMUNITYINFORMATION1. If IhecommunityofficialresponsibleforverifyingbuildingelevationsspecifiesthaithereferencelevelindicatedinSectionC, Item 1isnolthe "lowestfloor" asdefinedinthecommunily's floodplainmanagementordinance, Ihe elevationofthebuilding's "lowest floor" as definedbytheordinanceis: L_b__l I ! _