FEMA-EC950703 (2)ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
A'i-rENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only toprovideelevationinformationnecessarytoensurecompliancewithapplicablecommunityfloodplainmanagementordinances, todeterminetheproperinsurancepremiumrate, 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 Fo~ INSURANCE COMPANY USE
BUILDING OWNER'S NAME
POLICY NUMBER
STREET ADDRESS (Including Apt., Unit. Suite and/or Bldg. Number) OR P.O. ROUTE AND BOX NUMSEH COMPANY NAIC NUMBER
OTHER DESCRIPTION (Lot and Block Numbers, etc,)
CITY
STATE
SECTION B FLdOD INSURANCE RATE MAP (FIRM) INFORMATION
ZIP CODE
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 J I t 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 Al-A30, AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an elevation
ell I J..5"~Jl I.~__] feet NGVD (or other FIRM datum-see'Section B, Item 7).
b). FIRM Zones V1-V30, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level from
the selected diagram, is at an elevation of I J I I I I.L_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 selected diagram is I I 1.1 I feet above [] or
below [] (check one) the highest grade adjacent to the building.
d). FIRM Zone AO. The floor used as the reference level from the selected diagram is I ! I.L_J feet above [] or below [] (check
one) the highest grade adjacent to 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 the above reference level elevations: [] NGVD '29 [] 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 [.~ee Sectinn B, Item 7]. then conver~ the e!e~ion~ to t,~e datu,? system used on the FIRM and show the conversion
equation under Comments on Page 2.)
4. Elevation reference mark used appears onFIRr~ Yes ~ No (See Instructions on Page 4)
5. The 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:l t L~lOl! I.~_J feet NGVD (or ot~~ta~-see
Section B, Item 7). ~.'"~.'~
CERTIFIER'S NAME LICENSE NUMBER (or Affix Seal)
TITLE ~ COMPANY NAME
CIT