FEMA-EC940616 (2)ELEVATION CERTIFICATE o.M.B.~o3067-0077
ExpiresMay 31, 1993
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ENTION: 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 Revision (LOMA or LOMR).
Instructions for completing this form can be fqund on the following pages.
SECTION A PROPERTY INFORMATION FOR INSURANCE COMPANY USE
BUILDI,~IG~WNER'S NAME ~'~'~"~'~'-.~ POLICY NUMBER
STREET ADDRESS (Including Apt., Uiit, SJ anJor B~g. Numar) OR P.O~UTE AND BOX NUMBER COMPANY NAIC NUMBER
OTHER DESCRIPTION (Lot and Bilk Nu~rs, etc.) ,j ~ ~ ~ ~
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): ~ '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: [ _L__L_J_I__I .[_ J feet NGVD (or other FIRM datum-see Section B, Item 7).
SECTION C BUILDING ELEVATION INFORMATION
Jsing the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best
Jescribes 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 Js at an elevation
of l I ~[.?l.l__J~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 b .!. _.L_L_[_..J ,b__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 L_J_J .b__~ 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 L_L_J .[_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: [~q'~VD '29 [] Other (descri .be
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.) ~ Ye/s4. Elevation reference mark used appears on FIRM: [] No (See Instructions on Page 4)
5. The reference level elevation is based on: ~ual 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._[ .~,}.[_~ feet NGVD (or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
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 "lowes!
floor" as defined by the ordinance is: {_ J_ J__L_J_..t .I._.] feet NGVD (or other FIRM datum-see Section B, Item 7).
2. Date of the start of construction or substantial improvement
SEE REVERSE SlOE FOR COI'ITINUAI*ION