849 BRUCE AVE .
� `� � 13 rvc �
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077
+ ��l�,Y1� ` :�'3�..�.- NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 2005
T,�.,�
���� �,_�7� ELEVATION CERTIFICATE
� Important: Read the instructions on a es 1-7.
SECTION A-PROPERTY OWNER INFORMATION Pa Insurance Canparry Use:
BUILDWG OWNER'S NAME Policy Number '>
MICHAEL BELANGER
BUILDING STREET ADDRESS(InGuding Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NQ Company NRIGNumber '
849 BRUCE AVENUE
C�Ty STATE ZIP CODE
CLEARWATER BEACH FL 33767
PROPERTY DESCRIPTION(Lot and Blodc Numbers,Tax Paroel Number,Legal Description,etc.)
LOT 1,BLOCK 42,MANDALAY AVENUE
BUILDING USE(e.g.,Residential,Non-residential,Addition,Acxessory,etc. Use a Comments area,'rf necessary.)
RESIDENTIA�
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ❑GPS(Type):
� �°_��_�.�^ o� #q�.�� ❑NAD 1927 ❑NAD 1983 ❑USGS Quad Map ❑Other.
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
61.NFIP COMMIJNffY NAME&COMMUNITY NUMBER B2.COUNTY NAME 63.STATE
CLEARWATER 125096 PINELLAS FL
B4.MAP AND PANEL B7.FIRM PANEL 69.BASE FLOOD ELEVATION(S)
NUMBER B5.SUFFIX B6.FIRM INDEX DATE EFFECTIVFJREVISED DATE B8.FLOOD ZONE(S) (Zone A0,use depih of iboding)
12103C0102 G 9-3-03 9303 AE 11
B10.Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in B9.
❑FIS Profile �FIRM ❑Community Determined ❑Other(Desaibe):
611.Indicate the elevation datum used for the BFE in B9:❑NGVD 1929 �NAVD 1988 ❑Other(Desaibe):
612.Is the builtling locatetl in a Coastal Bamer Resources System(CBRS)area or Othervuise Protectetl Area(OPA)? ❑Yes �No Designation Date_
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1.Builtling elevations are based orr 0 Construction Drawings' ❑Building Under Construction* �Fnished Construcfion
'A new Elevation Certificate will be requiretl when consUuction of the building is compiete.
•C2.Building Diagram Number 8(Select the building diagram most similar to the building for which this cerfificate 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,ARlA,ARIAE,ARIA1-A30,ARIAH,ARIAO
Complete Items C3.-a-i below aa:ortling 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,wnvert the datum to that used for the BFE.Show field measurements and datum conversion calculation. Use the spaoe provided or the Comments area of
Section D or Section G,as appropnate,to document the datum conversion.
Datum 1988 Conversion/Comments :�. � � - '
Elevation reference mark used Does the elevation reference mark used appear on the FIRI���No � � ���� �Lr��
o a)Top of bottom floor(induding basement or endosure) 4. 5 ft.(m) �;'"� �
o b)Top of next higher floor 11.2 ft.(m) �°� �� � � ,"�� `
o c)Bottom of lowest horizontal structural member(V zones only) N.A ft.(m) �� � � '" "�' _ :
o d)Attached garage(top of slab) 4. 5 ft.(m) � `f., w � °�-� �
o e)Lowest elevation of machinery andlor equipment � .• ,S ,; " �-� � �
serviang the building(Describe in a Comments area) 16.3 ft.(m) � p,,, Q, C�� `
@"� �
o �Lowest adjacent(finished)grade(LAG) 4.4 ft.(m) �`�._!,..-' � �� �z� ..
o g)Highest adjacent(finished)grade(HAG) 4. 4 ft.(m) �'u L�r� � (� �.. ,r
o h)No.of permanent openings(flood vents)within 1 ft.above adjacent grade 17 ��� �. � ' �—f t/-��j
o i)Total area of ali permanent c�enings(flood vents)in C3.h 5508 sq.in.(sq.cm) � h :
SECTION D-SURVEYOR,ENGINEER,OR ARCHffECT CERTI A N
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 fhe information in Sections A,B,and C on this certificate represents my best efforts to interpret fhe data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001.
CERTIFIER'S NAME M.G.MAYER LICENSE NUMBER4495
• TITLECEO COMPANY NAME FLORIDA BENCHMARK —
ADDRESS CITY STATE ZIP CODE
1298 LAKEVIEW RD. CLEARWATER FL 33756
SIGNATURE • ,��� DATE TELEPHONE
,� �L.`, 9-14-05 727-298-0286
FEMA Form 81-31,January 2003 See reverse side for continuation. Replaces all previous editions
IMPORTANT: In these spaces,copy the corresponding information from Section A >Forins�rai�oe Canpany use:
BUILDING STREET ADDRESS(induding Apt,Unit,Suite,andla BkJg.No.)OR P.O.ROUTE AND BOX N0. Pdicy Number
849 BR�CE AVENUE
CITY STATE ZIP CODE Canparry NAICNumber
��EARWATER BEACH FL 33767
SECTION D-SURVEYOR,ENGINEER,OR ARCHRECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community oifiaal,(2)insurance agenticompany,and(3)building owner.
CUMMENTS ',
AC ELEVATION 16.3,ELEVATION OF ELECTRIC BOX 17.2
❑Chedc here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(INITHOUT BFE)
For Zone AO and Zone A(without BFE),complete Items E1 through E4. If the Elevation Certificate is ir�ended for use as supporting informa8on for a LOMA or LOMR-F,
Section C must be completetl.
E1.Buiiding Diagram Number_(Select the building diagram most similar to the building for which this cer6ficate is being completed—see pages 6 and 7. If no diagram aa;urately
represents the buikiing,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 Building Diagrams 6-8 with openings(see page 7),the next higher 800r or elevated floor(elevation b)of the building is _ft,(m)_in.(an)above the highest adjaoent
grade. Complete items C3.h and C3.i on front of form.
E4.The top of the platform of machinery andlor equipment serviang the buiiding is _ft,(m)_in,(cm)❑above or ❑below(check one)the highest adjacent grade. (Use
natural grade,if available).
E5.For Zone AO only: If no flood tlepth number is available,is the top of the bottom floor elevated in acoordance with the communit�s floodplain management ordinance?
❑Yes ❑No ❑Unknown. The local official must certify this informa�on in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owners authorized representative who cbmpletes Sections A,B,C(Items C3.h�d C3.i only),and E for Zone A(without a FEMAassued or community-
issued BFE)or Zone AO must sign here. The statements in Sections A,8,C,and E are correct to the best of my knowledge.
•PROPERIY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
❑Chedc here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local offiaal who is authorized by law or ordinance to atlminister the communitys floodplain managemer�ordinance can oomplete Sections A,B,C(or E),and G of this Elevation
Certificate. Compiete 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 elevation data in the Comments area below.)
G2.�A community offiaal 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 fa community floodplain management purposes.
G4.PERMIT NUMBER G5. DATE PERMff ISSUED G6. DATE CERTIFICAIE OF COMPLIANCEIOCCUPANCY ISSUED
G7,This permit has been issued for:❑New Constru�ion ❑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
4
COMMENTS
❑Chedc here if attachments
FEMA Form 81-31,January 2003 Replaces all previous editions
a��°'`�s�c��¢�'�,'
� x�pb ��
��4���, ` �'��� CITY OF LEARWATER
i ������__� �
���-�. ,, ",Q�
�� : �y DEVELOPMENT & NEIGHBORHOOD SERVICES DEPARTMENT
"�,�',�9�� � rd,���,�'�g'�y PosT OFFicE Box 4748, Ci�.aawn�e, F►.o�u�A 33758-4748
�',f.��,����9 ,�4� MUNICIPAL SERVICES BUILDING, ZOO SOUTH MYRTLE AVENUE,CLEARWATER,FLO�uDn 33756
g�°�p`�� TELEPHONE�7Z� 562-4567 Fnx(72� 562-4576
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 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 sectioris by Community Official
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1. BUILDING OWNER'S NAME Policy Number
A2.BUILDING STREET ADDRESS(including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
CITY CLEARWATER 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. LAT�TUDE/LONGITUDE(OPTIONAL): HORIZONTAL DATUM: SOURCE:�GPS(Type):
(##°-##'-##.##" or ##.#####°) ❑ NAD 1927 ❑ NAD 1983 ❑ USGS Quad Map❑Other
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
NFIP COMMUNITY NAME&COMMUNITY NUMBER 62.COUNTY NAME 63.STATE
64.MAP AND PANEL B7.FIRM PANEL B9.BASE FLOOD ELEVATION(S)
NUMBER B5.SUFFIX 66.FIRM INDEX DATE EFFECTIVE/REVISED DATE B8�FLOOD ZONE(S) �Zone AO,use depth of flooding)
5/17/2005
610. 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)
B11. Indicate elevation datum used for BFE in 69:❑ 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)
C1. 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 (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,Vi-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 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 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:��� l-/V Community Official:
�evation certificates shall be mainfained by the community and copies with the attached memo made availab/e by request
FRANK HIBRARD,MAYOR
GEORGE N.CRE"1'EKOS,COUNCILMEMAER JOI W DORAN,COUNCILMEMBER
PAUL F.GIASON,COUNCILMEMBBR � CARI.EN A.PE"I'ERSEN,COUNCILMEMRER
��EQUAL EMPLOYMENT AND AFFIRMA'1'1VE AC1'ION EMPLOYEK��
° FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077
. ' ,
� •t NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 2005
���� -����I ELEVATION CERTIFICATE
Importarrt: Read the instructions on pages 1•7.
SECTION A-PROPERTY OWNER INFORMATION For Insur�nce Comp�ny Use:
�3UIlDING OWNER'S NAME Policy Number '
MICHEL BELANGER
BUILDING STREET ADDRESS(Induding Apt.,Unit,Suite,and/or Bidg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
849 BRUCE AVENUE
CITY STATE ZIP CODE
CLEARWATER FL 33767
PROPERTY DESCRIPTION(Lot and Blodc Numbers,Tax Parcel Number,Legal Description,etc.)
LOT 1,BLOCK42,MANDALAY
BUILDING USE(e.g.,Residen6al,Non-residential,Addition,Accessory,etc. Use a Comments area,if necessary.)
RESIDENTIAL
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ❑GPS(Type):
( ##°-##'-�f#.##" 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.COUNTY NAME B3.STATE
CLEARWATER 125096 PINELLAS FL
64.MAP AND PANEL B7.FIRM PANEL 69.BASE FLOOD ELEVATION(S)
NUMBER 65.SUFFIX B6.FIRM INDEX DATE EFFECTIVEIREVISED DATE 68.F100D ZONE(S) (Zone A0,use depih of flootling)
12103CA102 G 9-3-03 9,303 AE 11
B10.Indicate the source of the Base Flood FJevation(BFE)data or base flood depth entered in B9.
❑FIS Profile �FIRM ❑Community Determined ❑Other(Desaibe):
B11.Indicate the elevation datum used for the BFE in B9:�NGVD 1929 �NAVD 1988 ❑Other(Descdbe):
612,Is the building located in a Coastal Barrier Resources System(CBRS)area a Otherwise Protected Area(OPA)? ❑Yes �No Designation Date
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1.Building elevations are based on:�Construction Drawings" �Building Under Construcfion' ❑Fnished Construction
`A new Elevation Certificate will be required when cwistruc�on of the building is complete.
•2.Building Diagram Number 8(Select the building diagram most similar to the building for which this certificate is being completed-see pages 6 and 7. If no diagram
aocurately 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,AR/AE,ARIA1-A30,AR/AH,AR/AO
Complete Items C3.-a-�below aa:ording to the building diagram specified in Item C2.State the datum used.If the datum is d'rfferent 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 Sedion G,as appropriate,to document the datum conversion.
Datum 1988 ConversionlComments
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑Yes �No ���� ,,p��
o a)Top of bottom floor(induding basement or endosure) 11. 1 ft.(m) � C�
o b)Top of next higher floor N.A ft.(m) � �" �° v
o c)Bottom of lowest horizontal sUuctural member(V zones only) N.A ft.(m) o o N
o d)Attached garage(top of slab) 4, 5 ft.(m) � .. �
o e)Lowest elevation of machinery and/or equipment W,; � `�
serviang the building(Describe in a Comments arez) N.A ft.(m) �-° �
o fl Lowest adjacent(finished)grade(LAG) 3.7 ft.(m) z'� ` ` .
o g)Highest adjacent(finished)grade(HAG) 3. 7 ft.(m) ��
o h)No.of permaner�openings(flood vents)within 1 ft.above adjacent grade 0 �
J ��
o i)Total area of�I permanent openings(flood vents)in C3.h 0 sq.in.(sq.cm) 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.
I certify that the information in Sections A,8,and C on this certificate represents my best efforts fo interpret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code,Section 1001.
CERTIFIER'S NAME M.G.MAYER LICENSE NUMBER 4495
TITLE CEO COMPANY NAME FLORIDA BENCHMARK
DDRESS CITY STATE ZIP CODE
1298 LAKEVIEW RD. CLEARWATER FL 33756
SIGNATURE DATE TELEPHONE
� . �� 06-01-05 727-298-0286
FEMA Form 81-31,January 2003 See reverse side for continuation. Replaces all previous editions
�
IMPORTANT: In these spaces,copy the corresponding information from Section A. For insurance Company use:
BUILDIN�STR�ET F-0DR�SS(Induding Apt,Unit,Suite,arxUa Bkig.No.)OR P.O.ROUTE AND BOX N0. Policy Numtier
84°B�UCE A1,�NUE
�m' • ' STATE ZIP CODE Compar�y NA1C Numbet
CLEARWATER FL 33767
SECTION D-SURVEYOR,ENGINEER,OR ARCHRECT CERTIFICATION(CONTINUED)
- �;�y both sides of this Elevafron Certificate for(1)community offiaal,(2)insurance agenUcompany,and(3)building owner.
COMMENTS
BUILDING UNDER CONSTRUCTION,ELEVATIONED ON CRAWL SPACE.CRAWL SPACE ELEVATION 4.4.
❑Check here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WRHOUT BFE)
For Zone AO and Zone A(without BFE),oomplete Items E1 through E4. If the Elevation Cer�ficate is intended for use as supporting information for a LOMA or LOMR-F,
Section C must be completed.
E1.Buiiding Diagram Number_(Select the building diagram rrmst similar to the bu�ding 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 floa(induding basement or endosure)of the building is _ft.(m)_in.(cm)0 above or ❑below(chedc one)the highest adjacent gr�e. (Use
natural grade,if available).
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. Complete items C3.h and C3.i on front of form.
E4.The top of the plafform of machinery andlor equipment serviang the building is _ft.(m)_in.(cm)❑above or ❑below(chedc one)the highest adjacent grade. (Use
natural grade,if available).
E5.For Zone AO only: If no flood depth number is av�lable,is the top of the bottan floor elevated in accordance with the community's floodplain management ordinance?
❑Yes ❑No ❑Unknown. The local ofl'icial must certify this ir�ormation in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owners authorized representative who completes Sections A,B,C(Items C3.h�d C3.i only),and E for Zone A(without a FEMA�ssuetl or community-
issued BFE)or Zone AO must sign here. The statements in Sections A,B,C,and E are correcrf to the best of my knowledge.
pROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
�DRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
❑Check here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local offici�who is authorized by law or orclinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),and G of this Elevation
Certificate. Complete fhe applicable item(s)and sign below.
G1.0 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 ir�ormation. (Indicate 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�ssued BFE)or Zone A0.
G3.❑The following information(Items G4-G9)is provided for community floodplain management purposes.
G4.PERMIT NUMBER G5. DATE PERMfT ISSUED G6. DATE CERTIFICATE OF COMPLIANCEIOCCUPANCY�SSUED
G7.This permit has been issued for.❑New Constnx�ion ❑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
�NATURE ,, ,, m �- _ ,, DATE
�COMMENTS
❑Check here if attachments
FEMA Form 81-31,January 2003 Replaces all previous editions
•
.
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�b�,ati<4� � �.� CITY OF CLEARWATER
� ``�` ��i,, � �
,�.r-.\ � "°
h�a---'Y_ - .�
;;�--�a =� p� DEVELOPMENT & NEIGHBORHOOD SERVICES DEPARTMENT
�,t��—� �.
`�^�,��`'�.----- Q��� POST�FFICE BOX 4748� CLEARWATER� FLOa�DA 33758-4748
� d��/�aiswpA
+++y A���i�1�y� MUNICIPAL SERVICES BUILDING, IOO SOUTH MYRTLE AVENUE,CLEARWATER,FLO�uDn 33756
l�°"'�`i` TELEPHONE�7Z� 56Z-4S67 Fnx(72� 562-4576
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 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 Official
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1. BUILDING OWNER'S NAME Policy Number
A2.BUILDING STREET ADDRESS(including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
CITY CLEARWATER 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❑Other
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
1.NFIP COMMUNITY NAME&COMMUNITY NUMBER B2.COUNTY NAME 63.STATE
64.MAP AND PANEL 67.FIRM PANEL B9.BASE FLOOD ELEVATION(S)
NUMBER g5.SUFFIX 66.FIRM INDEX DATE EFFECTIVE/REVISED DATE B$•FLOOD ZONE(S) �Zone AO,use depth of flooding)
5/17/2005
610. 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 69:❑ NGVD 1929 ❑ NAVD 1988 ❑Other(Describe)
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Othervvise Protected Area(OPA)? ❑Yes ❑No Designation Date
SECTION C -BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1. Buiiding 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 (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 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 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:
�levation certificates shall be maintained by the community and copies with the attached memo made available by request
FRANK HIBRARD,MAYOR
GEORGE N.CRE'1'EKOS,COUNCILMEMBER JOIIN DORAN,COUNCILMEMB@R
PAUL F.G[RSON,COUNC[LMEMRBR � CARLEN A. PE7'ERSEN,COUNCILMGMRER
��EQUAL EMYLOYMEN'f AND E�F11tMA1'IVE ACTION EMPLOYER�