DeForest Rd-OS020621
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM,
ELEV A"f.10N CBRTIFICA TE:'
.O.M.e..No.3067-0077
Expires July 31, 2002
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.11111 ortant: Read the instructions on a es 1 -7.
SECTION A - PROPERTY OWNER IN'FORMATION
For Insurance Company Use:
Policy Number
BUILDING OWNER'S NAME
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. 0.) OR P.O. ROUTE AND B NO.
e.. ::::
CITY STATE
COereu...., -re~
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
LAT 1. ~ IL- 1- ~~ ANbtlAAlS MANo~
BUILD NG USE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use Comments section if necessary.)
CompanyNAIC Number
ZIP CODE
15D1~
LA TITUDE/LONGITUDE (OPTIONAL)
( ##0 _ ##' _ ##.##" or ##.#####0)
HORIZONTAL DATUM:
~NAD 1927 LI NAD 1983
SOURCE: LI GPS (Type):
LI USGS Quad Map ~Other: 'F12..M...
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER B3. STATE
I ~~
B9. BASE FLOOD ELEVATION(S)
(Zone AO, use depth of flooding)
.5"D
B8. FLOOD
-r ZONE(S)
-.J >' AE.
B 10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
I_I FIS Profile I~ FIRM 1-1 Community Determined 1-1 Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: I~ NGVD 1929 1-1 NAVD 1988 1-1 Other (Describe):
B12. Is the building located in a Coastal_Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?
Designation Date:
I_I Yes I~ No
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: I_I Construction Drawings* Building Under Construction* I_I Finished Construction
*A new Elevation Certificate 'fill be required when construction of the building is complete.
C2. Building Diagram Number ----L- (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 A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA, ARlAE, ARlA1-A30, ARlAH, ARlAO
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,
DatumN~IJ') l~ Convers~/Comments
Elevation reference mark usecL~ ~ftRllO Does the elevation reference mark used appear on the
Q a) Top of bottom floor (including basement or enclosure) +'0(, .4i'ft.(e) gj ." .....
Q b) Top of next higher floor . ===!= . _ ft.(m) ~ GI ,,~~G\ T E
Q c) Bottom of lowest horizontal structural member (II zones only) A- . _ ft.(m) ~ ~ ./ C?- '*
Q d) Attached garage (top ofslab) . _ ft.(m) ~ -g ...:. ..... ........ ,
Q e) Lowest elevation of machinery and/or equipment ~: o~.. .............. ODES
servicing the building tJJr. '_ ft.(m) ~ ~ ... -<) 36 1
1:1 f) Lowest adjacent grade (LAG) 4Ch .tB.- ft.(.) ~ ~ ~~?~ES \
Q g) Highest adjacent grade (HAG) qq; '. ~ ft,(_) ~ J\llfs'ij ,0'
Q h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade rJlc ~
1:1 i) Total area of all permanent openings (flood vents) in C3h IJ J,.- sq. in. (sq. em)
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 or imprisonment under 18 U. S. Code, Section 1001.
C IF ER' UqENSE NUMB J
SEE REVERSE SIDE FOR CONTINUATION
REPLACES ALL PREVIOUS EDITIONS
:t
For Insurance Company Use:
Policy Number
Company NAIC Number
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (C NTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
COMMENTS
.t, ,.'
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, ,I I CheCK here if ~ttachments
SECTION E _ BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO ANO ZO"~ A ~ITH9UT ~FE)
For Zone AO ;and ?one A (without BFE), complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting
information for a [OMA or LOMR-F, Section C must be completed.
E1. 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 LI_I ft.(m) LLlin.(cm) LI above or LI below
(check one) the -hlgtiest 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
I_LI ft.(m) 1_1_lin.(cm) above the highest adjacent grade.
E4. For Zone AOol1ly: 'If no flood depth number'is available:is the; top of the bottom floorelevafed in. accordance with the.oo~munlty's'
floodplain management ordinance? I I Yes LI No I I Unknown. The local official must certify this information in Section G:
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION
The proper;ty owner or owner's authorized representative who completes Sections h., B, and E for Zone A (without a FEMA-issuecl or
community-issued BFE) or Zone AO must sign here.
It
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS
CITY
STATE
ZIP CODE
SIGNATURE
DATE
TELEPHONE
COMMENTS
I 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
Sectiol15 A, B, C (or E), and G of this Elevation Certificate, Complete the applicable item(s) and sign below, " "
G1. I=--r The information in Section C was tal<..en from oth~r-documentation that has been 'signed and embo!>sed 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. I_I A community official completed Section E for a buil~i'~g located in Zone A (without a FEMA-issued or community-issued BFE) or
Zone AO. '
G3. I_I The following information (Items G4-G9) is providecl,for community floodplain management purposes,
G4. PERMIT NUMBER G5. DME PERMIT IS,StlED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
.,. I . ISSUED
G7. This permit has been issued for: LI New Construction LI Substantial Improvement
G8. Elevation of as-built lowest floor (including basement) of the blJilding is:
G9. BFE or (in Zone AO) depth of flooding at the building site is:
LOCAL OFFICIAL'S NAME
, _ ft.(m) Datum:
. _ ft.(m) Datum:
TITLE
COMMUNITY NAME
TELEPHONE
SIGNATURE
DATE
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COMMENTS
.:
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I Check here if attachments
REPLACES ALL PREVIOUS EDITIONS
FEMA Form 81-31, AUG 99