FEMA-EC961024O.M.B.N.O. 3067-0077
ELEVATION CERTIFIC.ATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTION: Use of this cerlificate does not provide a waiver of the flood insurance purchase requirement. This form is used only
p~ovide elevation inlormalion necessary to ensure compliance with applicable community floodplain management ordinances, to
determine tile 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
BUILDING OWNER'S NAME
INSURANCE COMPANY USE
poucY NUM~- ....
STREET ADDRESS (Including Apt., U_nit, Suite and/or BI-d-~. ~l-ur~;r) O~ ~O ROUTE AND BOX NUMBER
O~HER DESCRIPTION (Lol and Block Numbers, et~ )
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): [~] 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 I J...! J..! .~__J 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
2(a). FIRM Zones A1-A30, AE, AH, and A (with BFE). The top of the reference level floor from the selecled diagram is at an elevation
of I.. I .I. 15L71 feet NGVD (or other FIRM datum-see Se~:tion B, Item 7).
b). FIRM Zones V1-V30, VE, and V (wilh BFE). The botlom of the lowest horizontal structural member of the reference level from
the selected diagram, is at an elevation of L..__! I___J_ ~. !.! ! feet NGVD (or other FIRM datum-see Section B, Item 7).
c). FIRM Zone A (without BFE). The floor used as the reference level from the selecled diagram is ~__J~J .l ~ feel above L~ or
below [~ (check one) the highest grade adjacent lo the building.
d). FIRM Zone AO. The floor used as the reference level from the selecfed diagram is [_.J__l .~_J feet above I~l or below [~ (check
one) lhe highest grade adjacent 1o 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? [] Yes ~__] No [_~ Unknown
3. Indicate the elevation datum system used in determining tile above reference level elevations: [__~NGVD '29 I~l 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: f~'~ Yes [~No (See Instructions on Page 4)
5. Tile reference level elevation is based on: _L-~_ actual construction ~ construction 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 the lowest grade immediately adjacent to the building is: ~__[_~[~-J~l .{L~ .feet NGVD (or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
1. If the community official responsible for verifying building elevations specifies that 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 "lowesl
floor" as defined by the ordinance is: [__~___L_[ _i I.I !teet NGVD (or other FIRM dalum-see Section B, Ilem 7).
2. Date of the start of construction or substantial improvement
FEMA Form 81-31, MAY 93 REPLACES ALL PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUA11ON