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FEMA-EC001129FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE O.MB. NO. 30~'~-0(~77 Expires July 31, 2002 Important: Read the instructions on pa~les 1 - 7. SECTION A - PROPERTY OWNER INFORMATION BUILDING OWNER'S NAME For Insurance company use: Poli~ NUmar BUILDING .STREET ADDRESS (Includi,ng__Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. TATE ZIP CODE 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) o _ ~,. ~.~,, or ~If.5~]~]££°) HORIZONTAL DATUM: LI NAD 1927 LI NAD 1983 SOURCE: LI GPS (Type): I__1 USGS Quad Map I~1 Other: SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B2. COUNTY NAME I B3. STATE lB1. NFIP COMMUNITY NAME & COMMUNITY NUMBER I B4. MAPAND PANEL B5. SUFFIX [ B6. FIRM INDEX B7. FIRM PANEL I B8. FLo~OODNUMBERDATEEFFECTIVE/REVISED DATE Z (S) B10. Indi~te the source of the Base Flood Elevation (BFE) data or base ,~d ~epth entered in Bg. I_1 FIS Profile LI FIRM ~ Communi~ Deter/ned I__1 Other (Des~be): Bl1. Indi~te the elevation datum used for the BFE in B9: I~[ NGVD 1929 I~ NAVD 1988 ~1 Other (Describe): B12. Is the building Io~ted in a Coastal Barrier Resour~s System (CBRS) ama or Other/se Prote~ed Ama (CPA)? ~1 Yes Designation Date: B9. BASE FLOOD ELEVATION(S) Zone AC, use depth of flooding) No SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: I__lConstruction Drawings* ~Building Under Construction* I~lFinished Construction A new Elevation Certificate will be required when construction of the building is complete· C2. 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.) 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/AC 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 .-~t'~n"t ~--~ ~-~_~Does the elevation reference mark used appear on the FIRM? I_1 Yes ILY4~No a) Top of bottom floor (including basement or enclosure) ~'C)~t- b) Top of next higher floor c) Bottom of lowest horizontal structural member (V zones only) d) Attached garage (top of slab) I~ e) Lowest elevation of machinery and/or equipment servicing the building f) Lowest adjacent grade (LAG) Q g) Highest adjacent grade (HAG) Q h) No. of permanent openings (flood vents) within I f. above adjacent grade i) Total area of all permanent openings (flood vents) in C3h ff.(m) ~ oa I ~'O~?~,,~';",.~"E'6'.? ~. E~ ~ ~ aARR~S. RHODES ff.(m) ~ ~.~.~ ......... ~...~ 0~ . ~ff.(m) z.~ ~.~ 0 · . } fl.(m) ~ 1%%~~~:~ SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION 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 orimpdsonment under 18 U.S. Code, Section 1001. CERTIFIER'S NAME LIC,~{JMBER ADDRESS SIGNATU~~ COMPANY N~ME ~ 1_~ E,~_~ ZIP CODE TEL~HONE FEMA Form (~'~1, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES .ALL PREVIOUS EDITIONS IMPORTAN'~': In' these spaces, copy the corresponding information from Section A. , ~ For InSUrance Company use: BUILD;I~G STRE_F,.~ ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. PoliCy NUmar Z.W( ~(~O~/v~O~rT' ~ STATE ZIP CODE I C°mpanY NAIC Number CITY 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 I_1 Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zone AO and Zone A (without BFE), complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting information for a 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) ItL_lin.(cm) I_._l above or Itl 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 Itltl ft.(m) Itl__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 mana~lement ordinance? I I Yes I I No I 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 ownefs 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__1 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. Gl. I__l The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, engineer, or architect who is authorized by state or local law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. Itl A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or Zone AO. G3. Itl The following information (Items G4-G9) is provided for community floodplain management purposes. G4. PERMIT NUMBER · G5. DATE PERMIT ISSUED I G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY I ISSUED G7. This permit has been issued for: Itl New Construction [__l Substantial Improvement G8. Elevation of as-built lowest floor (including basement) of the building is: G9. BFE or (in ;~one m©) depth of flooding at the building site is: ft.(m) Datum: ft.(m) Datum: LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS I_1 Check here if attachments FEMA Form 81-31, AUG 99 REPLACES ALL PREVIOUS EDITIONS