656 BAYWAY BLVD UNIT 2 ' FEDERAL EMERGENCY MANAGEMENT AGENCY
°L��� w �4�� NATIONAL FLOOD INSURANCE PROGRAM O.M.B. No. 3067-0077
, Expires December 31, 2005
� x�• ELEVATION CERTIFICATE
ti Important: Read the instructions on pages 1-7. �-� • ��.�2� 7--2-
SECTION A-PROPERTY OWNER INFORMATION For Insurance Canpany Use:
BUILDWG OWNER'S NAME Policy Number
BAYWAY TOWNHOMES, LLC [`T'
BUILDING STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
BAYWAY BOULEVARD (o (�, �- Lt�� �LV p
CITY STATE ZIP CODE
CLEARWATER FLORIDA 33767
PROPERTY DESCRIPTION(Lot and Bloc�c Numbers,Tax Parcel Number,Legal Desaiption,etc.)
Lots 15-18 Bayway Subdivision No.5 P.B.38,PGS.38-39
BUILDING USE(e.g.,Residential,Non-residential,Addition,Accessory,etc. Use a Comments area,'rf necessary.)
RESIDENTIAL
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ❑GPS(Type):
( ##°-##'-##.#!K' or ##.##�1#°) ❑NAD 1927 ❑NAD 1983 ❑USGS Quad Map ❑Other:
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
61.NFIP COMMUNITY NAME&COMMUNITY NUMBER B2.CWMY NAME 63.STATE
City Of Cleafwatef 125096 PINELLAS FLORIDA '
64.MAP AND PANEL - B7.FIRM PANEL 89.BASE FLOOD ELEVATION(S}
NUMBER B5.SUFFIX . B6.FIRM INDEX DATE EFFECTIVEIREVISED DATE B8.FLOOD ZONE(S) (Zone A0,use depih of flooding)
125096-0007 D AUGUST 19,1991 AUGUST 19,1991 AE ' EL11.0
610.Indicate the source of the Base Flood ElevaUon(BFE)data or base flood depth entered in B9. '
❑FIS Profile �FIRM ❑Community Determined ❑Other(Describe):_
611.Indicate the elevation datum used for the BFE in 69:❑NGVD 1929 �NAVD 1988 ❑Other(Describe):_
B12 Is the building located in a Coastal Barrier Resources System(CBRS)area or Otheiwise Protected Area(OPA)? ❑Yes �No Designation Date
SECTION C-BUILDING EI.EVATION INFORMATION(SURVEY REQUIRED)
C1.Building elevations are based on:�Construction Drawings' �Building Under Construction' ❑Fnished Construction •
�A new Elevation Cerfificate wili be required when construction of the building is complete.
C2.Building Diagram Number 7 (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,AWA,AWAE,AWA1-A30,AR/AH,AR/AO
Complete Items C3.-a�below according to the building diagram specfied 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 6eld measurements and datum conversion calculation. Use the space provided or the Gomments area of
;�<;
Seclion D or Section G,as appropnate;to document the datum conversion. '
l�,......,.
Datum NAVD 1988 ConversioNComments NIA
.,
�
�a,
Elevation reference mark used N/A Does the elevation reference mark used appearon the FIRM? ❑Yes �No _`" # ` �a�i4���� � ` ��
o a)Top of bottan floor(induding basement or endosure) 17.70 . FT ft.(m) � '��`R,•', � }'�, ,�j�°�
o b)Top of next higher floor N/A . FT ft.(m) � �. '��`�, � u��'� �' '�, ,
o c)Bottom of lowest honzontal structurai member(V zones only) N1A . FT ft.(m) o� '�;� u� � ;�'`�
o d)aflached garage(top of block) 7.20 . FT ft.(m) W� ; ,, :� r � H � ; w °
o e)Lowest elevation of machinery and/or equipment �d, ;� ��Y f.r f,� F
s ervi an g the buildin g(De§cribe in a Comments area) NIA . FT ft.(m) �� : .. :, �' ``�= �
o fl Lowest adjacent(finished)grade(LAG) 5.0 . FT ft.(m} z'� ; :'�a�' .',t*'� �
0 9)Highest adjacent(finished)grade(HAG) 5.1 . FT ft.(m) �� ' �s';���`�/'���, �
o h)No.of permanent openings(flood vents)within 1 ft.above adjacent grade WA � '�� .•�
o i)Total area ofiall permanent openings(flood vents)in C3.h N!A sq.in. �
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 fhe information in Sections A,B,and C on this cerfificate represenfs my best efforfs to interpret the data avaifable.
1 understand fhat any false statement may be punishable by fine or imprisonmenf under 18 U.S. Code,Section 1001.
CERTIFIER'S NAME LICENSE NUMBER
BRUCE A.KLEW PLS 5052
TITLE COMPANY NAME
PRESIDENT KLEIN&STAUB SURVEYING,INC.
ADDRESS CITY STATE ZIP CODE
8016 Old Counry Road 54 New Port Richey FL 34653
SIGNATURE DATE TELEPHONE
02116/04 (727)834-8140
FEMA Form 81-31,January 2003 See reverse side for continuation. Replaces ail previous editions
IMPORTANT: In these spaces,copy the corresponding informa6on from Section A. Fa�nsurance c««„pany use: �
BUILDING STREET ADDRESS(Induding Apt,Uni�Su'�e,and/or Bldg.No.)OR P.O.ROUTE AND BOX N0. Policy Number
BAYWAY BOULEVARD •
CI'fY STATE ZIP CODE Company NAIC Number
CLEARWATER FLORIDA 337g7 }
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation CeRificate for(1)community oifiaal,(2)insurance agent/company,and(3)building owner.
COMMENTS
N/A
❑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 Eleva6on Certificate is intended for use as supporting information for a LOMA 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 fhe bottom floor(induding basement or endosure)of the building is _ft.(m)_in.(cm)�above or ❑below(chedc one)the highest adjacent grade. (Use
natural grade,'rf available).
E3.For Building Diagrams 6-8 with openings(see page�,the next higher floor or elevated floor(elevation b)of the buiiding is _ft.(m)_in.(cm)above the highest adjacent
grade. Complete items C3.h and C3.i on front of form.
E4.The top of the piafform of machinery and/or equipment serviang the building is _ft.(m)_in.(cm)❑above or ❑below(chedc one)the highest adjacent grade. (Use
natural grade,if availabie).
E5.For Zone AO only: If no flood depth number is av�lable,is the top of the bottom floor elevated in accordance with the communi�'s 800dplain management ordinance?
❑Yes ❑No ❑Unknown. The local offiaal must certify this informafion in Section G.
SECTtON F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The properry owner or owners authorized representative who canpletes Sections A,B,C(Items C3.h and C3.i only),and E for Zone A(without a FEMA-issued or community-
issued BFE�or Zone AO must sign here. The sfatements in Secfions A,8,C,and E are correct to the best of my knowledge.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
❑Check here if attadiments
_ SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local offic�al who is authonzed by�aw a ordinance to administer the community's floodpl�n management ordinance can complete Sections A,B,C(or E),and G of this Elevation
Certificete. C^rripiete fhe ap�"�^abie item(s)and sign below.
G1.�The intormation in S2ction C was t��fcen from other documentaUon that has been signed and embossed by a licensed surveyor,engineer,or arc:hitect who is authorized by state
or loc�law�certiry eley�tion information. (Indicate the source and date of the elevation data in the Comments area below.)
G2,�A corrxnunity official co�leted�eetion E for a buiiding located in Zone A(without a FEMA-issued or community-issued BFE)or Zone A0.
G3.�The fdlo�+ir�g mformati�:(lt�ms G4-G9)is provided for communiiy floodplain management pwposes.
G4.PERMIT NUMBER G5. DATE PERMIT ISSUED G6.DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED
G7.This permit has been issued for.�New Construction ❑Substantial Improvement
G8.Elevation of as-built lowest floor(induding basement)of the building 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 TELEPHONE
SIGNATURE DATE
COMMENTS
❑Check here if attachments
FEMA Form 81-31,January 2003 , Replaces all previous editions
:�--�-
` FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077
�4:-�'
� - NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 2005
� ' ELEVATION CERTIFICATE
` �,���_ p�}y Important: Read the instructions on pa es 1 •7. �s Q� b z o z '�'! '7- Z
SECTION A•PROPERTY OWNER INFORMATION Fw insuranoe Company Use:
BUILDING OWNER'S NAME Policy Number
BAYWAYTOWNHOMES, LLC Uis�T Z !
BUILDING STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.RO�1TE AND BOX NO. Company NAIC Number
�� AYWAYBOULEVARD
CITY STATE ZIP CODE
CLEARWATER FLORIDA 33767
PROPERTY DESCRIPTION(Lot and Blodc Numbers,Tax Parcel Number,Legal Description,etc.)
Lots 15-18 Bayway Subdivision No.5 P.B.38,PGS.38-39
BUILDING USE(e.g.,Residential,Non-residential,Addition,Accessory,etc. Use a Comments area,ff necessary.)
RESIDENTIAL
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ❑GPS(Type):
( ##°-##'-##.##" or ##.�°) ❑NAD 1927 ❑NAD 1983 ❑USGS Quad Map ❑Other.__
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION �
61.NFIP COMMUNITY NAME&COMMUNITY NUMBER B2.COUMY NAME 63.STATE
City of Clearwater 125096 PINELLAS FLORIDA
64.MAP AND PANEL 67.FIRM PANEL B9.BASE FLOOD ELEVATION(S)
NUMBER B5.SUFFIX B6.FIRM INDEX DATE EFFECTIVEIREVISED DATE 68.FLOOD ZONE(S) (Zaie A0,use depth of flooding) -
125096-0007 G SEPTEMBER 03,2003 SEPTEMBER 03,2003 AE EL.11.0
B10.Indicate the source of the Base Fiood 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 69:�NGVD 1929 �NAVD 1988 ❑Other(Describe):
612 Is the building located in a Coastal Bamer Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes �No Designation Date_
SECTION C•BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1.Building elevations are based on:0 Construction Drawings' ❑Building Under Construdion` �Finished Construction
*A new Elevation Certi6cate will be required when construction of the building is complete.
�2.Building Diagram Number 7 (Select the building diagram most similar to the building for which this ceRificate is being compieted-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 BF�,VE,V1-V30,V(with BFE),AR,AWA,AR/AE,AWA1-A30,ARIAH,ARIAO
Complete Items C3:a-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 appropnate,to document the datum conversion. ,.,'',, .;
Datum NAVD 1988 ConversionlComments N/A � a }
Elevation reference mark used NIA Does the elevation reference mark used appear on the FIRM? ❑Yes �No � �� ��
.� 3.�h� .' ,. �✓_
o a)Top of bottom floor(induding basement or endosure) 7.20 . FT ft.(m) � R�s �.�� ��. �
1770 . FT ft.m cn ,�+. .{'�;:q> ° .',.a.
o b)Top of next higher floor � ) � • . w,_. ,..-�,- �' �
e� a
o c)Bottom of lowest honzontal structurai member(V zones only) N/A . FT ft.(m) �o .,,� '3;' @� �
o d)attached garage(top of biock) 7.20 . FT ft.(m) �� •: :� . �-
W N,r i . � r �„y
o e)Lowest elevation of machinery andlor equipment � d : ,y
serviang the building(Describe in a Comments area) N/A . FT ft.(m) ?� ; ' ,�� � � ' s, �"
o fl Lowest a djacent(f inis h e d)g r a de(L A G) 5.0 . F T ft.(m) z� � �' .d,; ' ''
o g)Highest adjacent(finished)grade(HAG) 5.1 . FT ft.(m) U � ' `�,j`�fl6{1 C�,f3�4�'�
o h)No.of permanent openings(flood vents)within 1 ft.above adjacent grade 14 � �
o i)Total area of all permanent openings(flood vents)in C3.h 1280 sq.in.
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 thaf the information in Secfions A,B,and C on this certificate represenfs my best efforts fo interpret the data available.
1 understand thaf any false stafement may be punishable by fine or imprisonment under 18 U.S.Code, Secfion 1001.
CERTIFIER'S NAME LICENSE NUMBER
BRUCE A.KLEIN PLS 5052
TITLE COMPANY NAME
•PRESIDENT KLEIN&STAUB SURVEYING,INC.
ADDRESS CITY STATE ZIP CODE
8016 Old County Road 54 New Port Richey FL 34653
SIGNATURE DATE TELEPHONE
.
. 06/16/04 (727)834�140
FEMA Form 81-31,January 2003 See reverse side for continuation. Replaces all previous editions
�
IMPORTANT: In these spaces,copy the corresponding information from Sec�ion A. Fortnsuranoe Company use: • , '
BUILDING STREET ADDRESS(Induding Apt,Unit,Suite,andlor BkJg.No.)OR P.O.ROUTE AND BOX N0. Policy Number •
BAYWAY BOULEVARD `
CITY STATE ZIP CODE Com n NAIC N • • '
CLEARWATER FLORIDA 33767 �Y �r ,
SECTION D-SURVEYOR,ENGIN�ER,OR ARCHITECT CERTIFICATION(CONTINUED) . �
Copy both sides of this Elevation Certficate for(1)community oifiaal,(2)insurance agent/company,and(3)building owner.
COMMENTS
N/A
❑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 Elevation Certificate is intended for use as suppoRing information for a LOMA 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(induding basement or endosure)of the building is _ft.(m)_in.(cm)�above or ❑below(chedc one)the highest adjacent grade. (Use
natural grade,if available).
_ E3.For Buiiding Diagrams 6�with openings(see page 7),the next higher floor or elevated 800r(elevation b)of the building is _ft.(m)_in.(an)above the highest adjacent
_ grade. Complete iiems C3.h and C3.i on front of form.
E4.The top of the platform of machinery andlor equipment serviang the building is _ft.(m)_in.(cm)�above or ❑below(chedc one)the higtiest adjacent grade. (Use
natural grade,'rf available).
E5.For Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in acxordance with the communii�s floodplain management ordinance?
❑Yes ❑No ❑Unknown. The local offiaal must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owners authorized representative who c�mmpletes Sec6ons A,B,C(Items C3.h and C3.i only),and E for Zone A(without a FEMA-issued or community-
issued BFE)or Zone AO must sign here. The statements in Sections A,B,C,and E are correct to the best of my knowledge.
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 authonzed by!aw 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 it�m(s)and sign below.
G1.�The information in Sec6on 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 io cer+Jfy elevation information. (Indicaie the source and date of the elevation data in the Comments area below.)
G2.�A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone A0.
G3.�The fdlowing information(Items G4-G9)is provided for community floodpiain management purposes.
G4.PERMff NUMBER G5. DATE PERMIT ISSUED �6. DATE CERTIFICATE OF COMPLIANCEIOCCUPANCY ISSUED
G7.This permit has been issued for:�New Construction ❑Substantial Improvement
G8.Elevation of as-built lowest floor(induding basement)of the building 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 TELEPHONE
SIGNATURE DATE •
COMMENTS
❑Check here if attachments
FEMA Form 81-31,January 2003 Replaces all previous editions
�
.
.
., ,}
.
• '
MEMO OF REVIEW FOR CORRECTNESS 8�COMPLETION
In accordance with participation in the NFIP/CRS program,all elevation certificates are required to be reviewed for correctness and completion prior to
acceptance by the community. This complete form shall be attached to ail elevation certificates maintained on file and provide with requested copies of
elevation certificates.
The attached elevation certificate requires corrections by the surveyor of section(s) prior to acceptance by the community
The attached elevation certificate is complete and correct
Minor corrections have been made in the below marked sections by Community Official
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1. BUILOING OWNER'S NAME Policy IVumber
A2.BUILDING STREET ADDRESS(including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. CQmparly NAIC Number `
CITY STATE ZIP CODE
A3. PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
A4. BUILDING USE(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)
A5. LATITUDE/LONGITUDE(OPTIONAL): HORIZONTAL DATUM: SOURCE:❑GPS(Type):
���_��_�,�^ o� �,�#°) ❑ NAD 1927 ❑ NAD 1983 ❑USGS Quad Map❑Other
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
.NFIP COMMUNITY NAME&COMMUNITY NUMBER B2.COUNTY NAME 63.STATE
84.MAP AND PANEL B7.FIRM PANEL B9.BASE FLOOD ELEVATION(S)
NUMBER B5.SUFFIX B6.FIRM INDEX DATE EFFECTIVE/REVISED DATE B$•FLOOD ZONE(S) �Zone AO,use depth of flooding)
12103C-0104
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 69.
❑FIS Profile ❑FIRM ❑Community Determined ❑Other(Describe) •
611. �ndicate elevation datum used for BFE in B9:❑ NGVD 1929 ❑NAVD 1988 ❑Other(Describe)
B12. Is the buildin located in a Coastal Barrier Resources S stem CBRS area or Otherwise Protected Area OPA 7 ❑Yes ❑No Desi nation Date
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1. Building elevations are based on: ❑Construction Drawings* ❑Bwldmg Under Construction* ❑Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Building Diagram Number (Select the building diagram most similar to the buiiding 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 C3.-a-i beiow 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.
�Datum Conversion/Comments
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑Yes ❑No
e) Lowest elevation of machinery or equipment servicing the buiiding(Describe in Comments area) ft•(m)
h) No.of permanent openings(flood vents)1 ft.above adjencent grade
i) Total area of all permanent openin s(flood vents)in C3.h sq.in.(sq.cm)
Comments: , '
Date of Review: �r �� _ Community Official:
All elevation ceRificates shall be maintained by the community and copies with the attached memo made available by request
�
� . �.
.
�'�����c�� CITY OF CLEARWATER
� v ,�li, �
� J p DEVELOPMENT &NEIGHBORHOOD SERVICES DEPARTMENT
9� � ` ` POST OFFICE BOX 4/4S� CLFARWATER� FLOx�Dn 33758-4748
�',qTE �� MUNICIPAL SERVICES BUILDING, 100 Sov'r[3 MYx'r[.E AvErruE,CLEARWATER,FLO�uDn 33756
TE�rxorrE(72� 562-4567 Fnx(72� 562-4576
MEMO OF REVIEW FOR CORRECTNESS&COMPLETION
In accordance with participation in the NFIPlCRS program,all elevation certificates are required to be reviewed for correctness and completion prior to
acceptance by the community. This complete form shall be attached to all elevation certificates maintained on file and provide with requested copies of
elevation certificates.
The attached elevation certificate requires corrections by the surveyor of section(s) prior to acceptance by the community
The attached elevation certificate is complete and correct
X Minor corrections have been made in the below marked sections by Community O�cial
SECTION A-PROPERTY INFORMATION For losurance Company Use:
A1. BUILDING OWNER'S NAME Policy Namber
A2.BUILDING STREET ADDRESS(including Apt.,Unit,Suite,and/or Bidg.No.)OR P.O.ROUTE AND BOX N0. Company NAIC Number
CITY STATE ZIP CODE
A3. PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
A4. BUILDING USE(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)
A5. LATITUDE/LONGITUDE(OPTIONAL): HORIZONTAL DATUM: SOURCE:❑GPS(Type):
���_��_�,�^ or �.�°) ❑ NAD 1927 ❑ NAD 1983 ❑USGS Quad Map 0 Other
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
.NFIP COMMUNITY NAME&COMMUNITY NUMBER 82.COUNTY NAME 63.STATE
64.MAP AND PANEL g5.SUFFIX B6.FIRM INDEX DATE B�•FIRM PANEL gg.FLOOD ZONE(S) B9•BASE FLOOD ELEVATION(S)
NUMBER EFFECTIVE/REVISED DATE (Zone AO,use depth of flooding)
12103C-0104
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9.
❑ FIS Profile ❑ FIRM ❑Community Determined ❑Other(Describe)
611. Indicate elevation datum used for BFE in B9:� NGVD 1929 ❑NAVD 1988 ❑Other(Describe)
B12. Is the buildin located in a Coastal Barrier Resources S stem CBRS)area or Otherwise Protected Area OPA? ❑Yes ❑No Desi nation Date
SECTIQN C-BUILDING ELEVATION INFORMATION(SURVEY REGIUIRED)
C1. Building elevations are based on: ❑Construction Drawings" ❑ Building Under Construction' ❑ Finished Construction
*A new Elevation Certificate wiil be required when construction of the building is complete.
C2. 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.)
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 C3.-a-i below according to the buitding 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 Conversion/Comments
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑Yes ❑No
e) Lowest elevation of machinery or equipment servicing the building(Describe in Comments area) ft.(m)
h) No.of permanent openings(flood vents)1ft.above adjencent grade
i) Total area of all permanent openings(flood vents)in C3.h sq.in.(sq.cm)
Comments
Date of Review: Community Official:
All elevafion certificates sha/l be maintained 6y the community and copies with the attached memo made available 6y request
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Ft�nrrx Hisanx[�,MAYOR
GEORGE N.CRE7EKOS,COUNCILMEMBER JOIIN DORAN,COUNCI[MEMBER
PAUL F.GIRSON,COUNCILMEMBER � CARIEN A PE'1'ERSEN,COUNCIIMEMBER
��EQUAL EMPI,OYMENT AND AFFIRMATIVE ACTION EMPLOYER��