FEMA-EC000406ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to
provide elevation information necessary to ensure compliance with applicable community floodplain management ordinances, to
determine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Revisio~ (LOMA or LOMR).
Instructions for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION
BUILDING OWNER'S NAME
FOR INSURANCE COMPANY USE
POLICY NUMBER
STREET ADDRESS (Including Apt.. Unit, Suite and/or Bldg. Number) OR P.O. ROUTE AND BOX NUMBER
CITY
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
STATE ZIP CODE
Provide the following from the proper FIRM (See Instructions):
1. COMMUNITY NUMBER 2, PANEL NUMBER I 3. SUFFIX 4. DATE OF FiRM INDEX I 5. FIRM ZONE I 6. BASE(inAoFLOODzones, useELEVATIONdepth)
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 I ] I _l.[_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
of I__~___~_L~_~J .12lJ 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 .l_ I ~ I.l_~ feet NGVD (or other FIRM datum-see Section B, Item 7).
FIRM Zone A (without BFE) The floor used as the reference level from the selected diagram is I_ I I.L_J fee~ above ~-~ or
c). ~ · . , ,,
below L~ (check one) the highest grade adjacent to the DUi~oing.
d). FIRM Zone AC. The floor used as the reference level from the selected diagram is ~__~_1 .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 Ithat 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: [] Yes ~'No (See Instructions on Page 4)
5. The reference level elevation is based on: [] 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_ I~_L_J .I feet NGVD (or other FIRM datum-see
Section B, Item 7).
CERTIFIER'S NAME
TITLE
LICENSE NUMBER (or Affix S,;,,,,r
COMPANY NAME
E .....
ilding owner.
ADDRESS CITY
Copies should be m~of this Certificate for: 1} community official, 2) insurance agent/co p'
COMMENTS;