919 LANTANA AVE ..
O.M.B.NO. 3067•0077
ELEVATI�N CERTIFICATE ExpiresMay31,1996
FEDERAL EMERGENCY MANAGEMENT AGE;ICY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTION: 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 compiiance with applicable community floodplain manageme'nt 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 found on the tollowing pages.
SECTION A pROPERTY INFORMATION � FoR iNSURnNCe coMPnr,v use
BUILDING OWNER'S NAME POLICY NUMBER
�o/3L—k T E N� �7�STr 2 s o.�/
STREET ADDRESS(Incfuding Apt.,Unit,Suite and/or Bldg.Number)OR P.O.ROUTE AND BOX NUMBER COMPANY NAIC NUMBER
� G.4NTfi�N�9 iQVEi✓v�
OTHER DESCAIP710N(Lot and Biock Numbers,etc.)
G oT i T3���/c �� -� .4�/p y ��,.��,��y �c.�T��o,e i� ��-�-t- 3z
,
C�'ry STATE ZIP CODE
G!-tH2 rV�4 TC-s2 r�-
SECTION 8 FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
Provide the following from the proper FIRM (See Instructions):
1.COMMUN(TY NUMBER 2.PANEL NUMBER 3.SUFFlX 4.OATE OF FlRM INOEX 5.FlRM ZONE 6.BASE FLGOD ELEVATION
(in AO Zore.<.,use depth)
iz s o y� : o � � � � -i_ $.3 _ �-�z ��, o
•7. Indicate the elevation datum system used on the F1RM for Base Flood Etevations(BFE):�NGVD'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�feet NGVD(or other FIRM datum-see Section B,Item 7),
SECTION C BUILDING ELEVATION INFORMATION
1. Using the Eievation Certificate Instructions,indicate the diagram number from the diagrams found on Pages 5 and 6 that best
describes the subjeci building's reference level� . �
•2(a).FIRM Zones 1-A30,AE,AH,and A(with BFE). The top of the reference level floor ftom the selected diagram is at an elevation
of��,�.�feet NGVD (or other FIRM datum-see Section B,Item�. � . _
(b). FIRM Zones V1-V30,VE,and V(with BFE). The bottom of the lowest horizontal structural member of the reference level from
the selecied diagram,is at an elevation of ���.��feet NGVD(or other FIRM datum-see Section B,Item 7). �
(c}. F1RM Zone A(without BFE). The floor used as the reference level from the selected diagram is �.0 feet above� or
_ below r' (check one� the highest grade adjacent to the building. __ _ ___
• (d). FIRM Zone AO. The floor used as the reference level from the selected d�agram is W.0 feet above❑ or below�(check
one)the highest grade adjacent to the building. If no flood depth number is available,is the bulding's lowest floor(reference
. level)elevated in accordance with the community's floodplain managemertt ordinance? ❑ Yes ❑ No ❑ Unknown
3. Indicate the elevation datum system used in determining the above reference level elevations:�NGVD'29 0 Other.(describe
under CommerKs on Page 2). (NOTE: If the e/evation datum used�measuring the elewadons is dfferent than that used on -
the F1RM (see Secdon B.Item 7f, then converl the elevations to Ure daium system used on the�F1RM and show the conversion
equation under Comments on Page 2.)
4. Elevation reference mark used appears on FIRM:,�Yes ❑No (See Instructions on Page 4) - -
5.The reference level elevatlon is based an: �actual construcKion ❑ construction drawi�gs
(NOTE: Use of construcfion drawrngs is on/y valid if the building does not yet have the reference level Noor;n place,in which
case ihis certi6cate wr11 only be valid for the building during the cowse of construction. A post-construclion Elevation Certi6cate
will be required once construciion is comp/ete.)
6.The elevation of the lowest grade immediately adjacent to the buildng is:L1LL17J.0 feet NGVD(or other FIRM datum-see
Section B,Rem�. �
SECTION D COMMUNRY WFORMATION
� 1.If 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 flood ' managemer�ordinance,the elevation of the building's"lowest �
floor"as defined by the ordinance is: �� t NGVD(or other FIRM datum--see Section B,Item 7).
2.Date of the start of construction or substanti ' vement � �' -
FEMA Form 81-31,MAY 93 REPLACES ALL PREVIOUS EDlT10NS SEE REVERSE SIDE FOR CGrIT]NUA?1C�!
SECTION E CERTIFICATION
This certification is to be signed by a land surveyor, engineer, or architect who is authorized by state or local law to certify elevation
information when the elevation information for Zones A1-A30,AE,AH,A(with BFEj,V1-V30,VE,and V(with BFE)is required. �
Community officiais who are authorized by local law or ordinance to provide fioodplain management information,may als�sign the
certification. In the case of Zones AO and A(without a FEMA or community issued BFE),a building official,a property owner,or an ,
owner's representative may also sign the certification.
Reference level diagrams 6,7 and 8- Distinguishing Features-If the certifier is unable to certify to breakaway/non-breakaway wall,
enclosure size,location of servicing equipment,area use,wall operings,or unfinished area Feature(s),then list the Feature(s) not
included in the certificatio�under Comments below. The diagram number,Section C, Item 1,must still be entered.
/certify ihat the information in Secfions B and C on fhis certificate represents my best etforts to interpret ihe data availab/e.
1 under,stand thaf any false stafement may be punishable by fine or imprisonment under 18 U.S. Code,Secfion f001.
CERTIFIEFi'S NAMF _ LICENSE NUMBEA(or Affix Seal)
o I+N. .��:��'�r� �s� S10 S 3
4 � , _
TITLE , ��,��pa�..�;;,`, COMPANY4AME
LAN_a."''St1'RVE�;O�i,�>�:��4. POLARIS ASSOCIATES, INC.
ADDRESS. , �.�C,1 ,,' ,�: �
--� .... ..-'! ,a :�►m� � ,. CITY STATE ZIP
P.0.^`B �-c�' ' °' CLEARWATER �FL 3 4 618
SIGNATlJfiG�, � ' ,�, r,� ` '
;� DATE PHONE
�` ' �"��� �`"��" Z-/7- 97 - (813 ) 449-2775 •
.." ,� . ,,� � . .
Copie sh td be tnade otthis Certiflcate for: 1)community official,2)insurance agenUcompany,and 3)building owner.
� - �
COMMENTS:
: __ _ . •
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' _
_ � �M p+RI.ES, •
�8 � REAS.08 COLUMlIS
A � A A V
rONES ZONES mP1ES ZaNES ZONES
.. . � REFFAe6E - ,
� ��� - LEVa REf61ENCE - .
IEVa � LEVE7, . - .
.. B.£VA7pN �
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. . .,�.�.:::: ;..:i::'.C.:, ",;f BI4SE
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��pp � ..•.• ::.• �pR�,':: ,..� REFBI@ICE fL00D
REVA710N ��E �� GFiADE •. "e � ELEVATION
LEVEL �3RAOE
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t• .:...r•:::'::-�:• �%;ADJACENT::
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:i:�:;j 6RADE
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The diagrams above illusVate the points at which the elevations should be measured in A Zones and V Zones. �
Elevations for alf A Zones should be measured at the top of the reference level floor.
Elevations for all V Zones should be measured at the bottom of the lowest honzontal structural member. � � '
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