41 BAYMONT ST FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077
NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002
e w � 2 � �.�� � ELEVATION CERTIFICATE
Im ortant: Read the instructions on a es 1 -7.
SECTION A-PROPERTY OWNER INFORMATION For Insurance Company Use:
UILDING OWNER'SNAME Poiicy Number
FRENCHY'S OFF THE HOOK/C/O K/RK CONSTRUCTION
BUILDING STREET ADDRESS(Including Apt., Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number SS
41 BAYMONT STREET
CITY STATE ZIP CODE
CLEARWATER FL
PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
LOT 1, BLOCK"A", CLEARWATER BEACH PARK 1Sr ADDITION REPLAT, PLAT BOOK 21, PAGE 21
BUILDING USE(e.g.,Residential,Non-residential,Addition,Accessory,etc. Use Comments section if necessary.)
NON-RESlDENT
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ❑GPS(Type):
( ##°-##'-##.##" or ##.#�#1##°) ❑NAD 1927 ❑NAD 1983 ❑USGS Quad Map ❑Other:
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP COMMUNITY NAME 8 COMMUNITY NUMBER B2.COUNTY NAME 63.STATE
C1TY OF CLEARWATER 125096 PINELLAS FL
B4.MAP AND PANEL 85.SUFFIX 66.FIRM INDEX 67.FIRM PANEL 68.FLOOD B9.BASE FLOOD ELEVATION(S)
NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO,use depth of flooding)
125096 0007 D AUGUST 18, 1992 AUGUST 19,1991 AE EL11
610. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in 69.
❑ FIS Profile � FIRM ❑ Community Determined ❑ Other(Describe):
B11. Indicate the elevation datum used for the BFE in B9: � NGVD 1929 ❑ NAVD 1988 ❑Other(Describe):
612. is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes � No
Designation Date
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
Building elevations are based on: ❑ Construction Drawings` ❑ Building Under Construction* � Finished Construction
'A new Elevation Certificate will be required when construction of the building is complete.
C2. Building Diagram Number 1(Select the building diagram most simifar 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,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO
Complete Items C3a-i below according to the bui�ding 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 1929 Conversion/Comments
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑Yes � No
o a)Top of bottom floor(including basement or enclosure) 5.7 ft. � ���,, �
� Licen 1762
o b)Top of next higher floor N.A ft. � �R •� ��,�� '
o c)Bottom of lowest horizontal structural member(V zones only) N.A ft. y� > ,,�'"""''� J y�`
o d)Attached gara ge(to p of slab) N.A ft. W m ,���'�3��"�,'��� �
o e)Lowest elevation of machinery and/or equipment -,; w S� . , � � *; �
servicing the building N.A ft. E; ��f;A ;`, Q rt �`
o f)�owest adjacent grade(LAG) 5.4 ft. z' � �,�` �' '
y(D r�c� q Mi iY� • 9 t��� t#'
o g)Highest adjacent grade(HAG) 5.7ft. � % `� G��u,,,, ��,r�,°'
o h)No. of permanent openings(flood vents)within 1 ft.above adjacent grade NA � � ar a,,,,<�'" '".,�`
o i)Total area of all permanent openings(flood vents)in C3h NA sq. in. Date:'' ��°�>�E�r�°"'�
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.
1 certify that the information in Sections A, 8, and C on this certificate represents my best efforts to interpret the data available.
1 understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
��RTIFIER'S NAME LICENSE NUMBER
'SANDY"LLOVERAS LS 1762
��fLE COMPANY NAME
FLORIDA PROFESSION SUR MAPPER LLOVERAS BAUR AND STEVENS
ADDRESS CITY STATE ZIP CODE
29228 U.S.H/GNWAY 19 T CLEARWATER FLORlDA 33761
SIGNATURE DATE TELEPHONE
- -- - - e6ruarv 21.2001 727-7843965
FEMA Form 81-31,AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In these spaces,copy the corresponding information from Section A. For Insurance Company Use:
BUILDING STREET ADDRESS(Including Apt., Unit,Suite,and/or Bldg.No.)OR P.O. ROUTE AND BOX NO. Policy Number
CITY STATE ZIP CODE Company NAIC Number
SECTION D-SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community o�cial, (2)insurance agenUcompany, and (3)building owner.
COMMENTS
❑ 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 E/evation Certificate is intended for use as supporting
information for a LOMA or LOMR-F, Section C must be comp/eted.
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 _ft.(m)_in.(cm)� above or ❑ 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
_ft.(m)_in.(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 management ordinance? �Yes ❑ No ❑ Unknown. The local official must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's 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
❑ 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.
G1. ❑ 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
eley�ation data in the Comments area beiow.)
G2. ❑A�ommunity�ific;ia;c�rnpleted Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or
Zone A0. .'
G3. ❑The foli�wir�g informatior� (I;ems G4-G9)is provided for community floodplain management purposes.
G4.PERMIT NUNE+rR � G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
ISSUED
G7. This permit has�een issusd for: ❑ New Construction ❑ Substantial Improvement
G8. Elevation of as-built lowest floor(including basement)of the buiiding is: _ft.(m) Datum:
G9. BFE or(in Zone AO)depth of flooding at the building site is: _ft.(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TEI.EPHONE
SIGNATURE DATE
COMMENTS •
❑ Check here if attachments
FEMA Form 81-31,AUG 99 REPLACES ALL PREVIOUS EDITIONS