521 MANDALAY AVE (NORTH TOWER) r
- ^' FEDERALEMERGENCYMANAGEMENTAGENCY O.M.B. No. 3067-0077
, �O�i���/v h1ATI0NAL FLOOD INSURANCE PROGRAM Expires December 31,2005
� T° ELEVATION CERTIFICATE
Important: Read the instructions on pages 1-7.
SECTION A-PROPERTY OWNER INFORMATION For InsuranceC�rnpany Use:
BUILDING OWNER'S NAME Policy Number
J.M.C.Desi n&Develo ment Cor .
BUILDING STREET ADDRESS{including Apt,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Gompany NAIC Number
521 Mandalay Avenue °"
CITY STATE ZIP CODE
Ciean�vater FL 33767
PROPERTY DESCRIPTION(�ot and Block Numbers,Tax Parcel Number,Legal Description,etc.) �, -/� -�R/�
Lot 1"Belle Narbor'as recorded in Plat Book 125 Page 15 of the Public Records of Pinellas County,Florida G -V _
BUILDING USE(e.g.,Residential,Non-residential,Addition,Accessory,etc. Use a Comments area,if necessary.)
Multi-story residential
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: GPS(Type):
� �_�_��� o� #�,�� ❑NAD 1927 ❑NAD 1983 ❑USGS Quad Map ❑Other:
SEC710N B•FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP COMMUNITY NAME&COMtvtUNIT`(NUMBER 82.COUNTY NAME B3.STATE
City of Clearv✓ater Fbrida 125096 Independant City F�
84.MAP ANb PANEL 87.FIRM PANEL B9.BASE FLOOD ELEVATION(S)
NUMBER 65.SUFFIX B6.FIRM INDEX DATE EFFECTIVFJREVISED DATE B8.FLOOD ZONE(S) (Zone A0,use depih of flooding)
1250960007 D Ofl�18l1992 U8,�1911991 AE 10&11
810.Indicate the source of the Base Flood Eievation(BFE)data or base flood depth entered i��B9,
❑FIS Profile �FIRM ❑Community Determined ❑Other(Describe):
611.Intlicate the elevation datum used for the BFE in B9:�NGVD 1929 ❑NAVD 1988 ❑Other(Descnbe):
B12 Is the building located in a Coastal Barrier Resourr�es System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes �No Designation Date_
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1.Building elevations are basetl on:�Construction Drawings' �Building Under Construction' ❑Fnished Construction
"A new Elevation Certificate will be requiretl when construction of the building is complete.
C2.Building Diagram Number 1(Select the building diagrarn most similar to the building for which this cerUficate is being completed-see pages 6 and 7. If no tliagram
accurately represents the buiiding,provide a sketch or photograph.)
C3.Elevations-Zones A1-A30,AE�,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AWA,;�WAE,AWA1-A30,AWAH,AWAO
Compiete Items C3:a-i below aa:ording to the building dagram 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 field measurements and datum conversion ca�ulation. Use the space provided or the Comments area of
SecGon D or Sec6on G,as appropriate,to document the daium conversion.
Datum ConversionlComments
Eleva�on refierence mark used 5.10 ft Does the elevaGon reference mark used appear on the FIRM? ❑Yes �No
o a)Top of bottom floor(induding basement or endosure) 6. 6 ft.(m) � ti
o b)Top of next higher floor 11.1 ft.(m) `�
o c)Bottom of lowest horizontal stnictur�member(V zones only) _ ft.(m) o o (��
o d)Attached garage(top of slab) _ ft•(m) �� �
o e)Lowest elevation of machinery ancllor equipment �� ����/
serviang the building(Describe in a Comments area) 2.0 ft.(m) �@ �ti
o fl Lowest adjac�t(finished)grade(LAG) 6.0 ft.(m) z'N � M�
o g)Highest adjacent(finishai)grade(HAG) 6. 1 ft.(m) � � �
o h)No.of permanent openings(flood vents)within 1 ft.above adjacent gratle 0 �
o i)Total area of all permanent openings(flood vents)in C3.h 0 sq.in.(sq.cm)
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 ce�tify that the information in Sections A,B,and C on this certificate represents my best efforts to interpret the data available.
i understand fhat any false statement may be punishable by fine or imprisonment under 18 U,S.Code,Section 1001,
CERTIFIER'S NAME LICENSE NUMBER
Samuel Mark E3each l_S0006261
TITLE COMPANY NAME
Professional Surveyor and Mapper Florida Design Consultants,Inc.
ADDRESS ��i7Y STATE ZIPCODE
3030 Starkey E3oulevard Pdew Port Richey FL 34655
SIGNATURE� DATE TELEPHONE
� O2„-I2,.-2,OOq- (727)849-7588
FEMA Form 81-31,January 2003 See reverse side for continuation. Replaces all previous editions
' �i�rIPG'R7AIJT: In these spaces,copy the corresponding information from Section A. Forinsurance company use:
gUILD— ING STR[ET ADDRESS(Indudirg Apt,Uni�Su'de,arxi/or Bkig.No.)OR P.O.ROUTE AND BOX N0. :Policy Number
521 Mandalay Avenue
' CITY STATE ZIP CODE Gompany NAIC Number
Cleanr✓ater FL 33767
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community oifidal,(2)insurance agent/company,and(3)building owner.
COMMENTS
C3.a-Eleva6on given is bwest garage floor elevation
C3.b-E�evation given is lowest living floor elevation
C3.e-Elevation iven is to the bottom of the elevator shaft ❑Check here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(Wff HOUT BFE)'
For Zone AO and Zone A(without BFE),complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F,
Section C must t�e canpieted.
E1.Building Diagram Number_(Select the building diagram most similar to the building for which this certificate is being canpleted—see pages 6 and 7. If no diagram accurately
represents ihe 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,'rf available).
E3.For Building Diagrams 6-8 with openings(see page 7),the neact higher floor or elevated floor(elevation b)of ihe building is _ft.(m)_in.(cm)above the highest adjacent
gratle. Complete items C3.h and C3.i on front of form.
E4.The top of the plafform of machinery and/or equipment servicing the building is _ft.(m)._in.(cm)�above or ❑below(check one)the highest adjacent gratle. (Use
natural grade,if available).
E5,For Zone AO only: !f no flootl depth number is av�lable,is the top of the bottan floor elevated in accordance with the communit�s floodplain management ortlinance?
❑Yes ❑No ❑Unknown. 7he local offici�must certify this inforrnation in Section G.
SEC710N F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property awner or owner's authorized representative who compietes 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 statements in Sections 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 attachments
SEC710N G-COMMUNITY INFORMATION(OPTIONAL)
The local offiaal who is authorized by law or adinanoe to administer the communit�s floodplain management ordinance can complete Sections A,B,C(or E),and G of ihis Elevation
Certificate. Complete ihe applicable item(s)and sign below.
G1.�The information in Sec�on C was taken from other documenta6on 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. (Indir,�te the source and date of the elevation tlata in the Comments area below.)
G2.❑A community offiaal oompleted Sedion E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone A0.
G3.�The following informa6on{Items G4-G9)is provided for oommunity floodplain management purposes.
G4.PERMIT NUMBER G5. DATE PERMIT ISSUED G6.DATE CERTIFICATE OF COMPLIANCFJOCCUPANCY ISSUED
G7.This permit has been issued for:�New Construction ❑Substantial Improvement
G8.Eleva6on of as•built lowest floor(induding basement)of the building is: __ft.(m) Datum:_
G9.BFE or(in Zone AO)depth of flootling at the lwilding site is: __ft.(m) Datum:
LOCAL OFFICIAI_'S NAME TITLE
COMMUNIIY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
❑Check here if attachments
FEMA Form 81-31,January 2003 Replaces all previous editions
_._ _ ._ _ ..-. . __ _' --___.... � _ .. . T
� 1' �t ��b" � . TY F LEARWATER
� = $ CI o C
• ��.� ,.y���� F
� � " DEVELOPMENT & NEIGHBORHOOD SERVICES DEPARTMENT
v��
� a' ; `� POST�FFICE BOX 474g� CLEARWATER� FLO�DA 33758-4748
4� ' MUNICIPAL SERVICES BUILDING, ZOO SOUTH MYRTLE AVENUE,CLEARWATER,FLO�uDn 33756
TELEPHONE�72� 562-4567 Fnx(72� 562-4576
MEMO OF REVIEW FOR CORRECTNESS & 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 O�cial
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
521 MANDALAY AVE
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❑Other
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
I .NFIP COMMUNITY NAME&COMMUNITY NUMBER 62.COUNTY NAME � B3.STATE
64.MAP AND PANEL 67.FIRM PANEL 69.BASE FLOOD ELEVATION(S)
NUMBER B5.SUFFIX B6.FIRM INDEX DATE EFFECTIVE/REVISED DATE BS.FLOOD ZONE(S) �Zone AO,use depth of flooding)
8/19/1992
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 89.
❑ FIS Profile ❑ FIRM ❑ Community Determined ❑Other(Describe)
811. 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. 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,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/Ai-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)ift.above adjencent grade
i) Totai area of all permanent openings(flood vents)in C3.h sq.in.(sq.cm)
/
Comments: one si ned and sea/ vafion c i c e mitted for o ect b the surve or. Raised seal attached to rtifica e for address 5 0 5 Manda/a e.
Date of Review: Community Official: �
�vation certificates shall be ma tained by lhe community and copies with the attached memo made availab/e by iequest
FRANK HIBBARD,MAYOR
GEORGE N.CRE'1'EKOS,COUNCILMEMBER JOIIN DORAN,COUNCILMEMBER
PAUL F.GIBSON,COUNCILMEMAGR � CARI.EN A.PE7'ERSEN,COUNCILMLMRER
��EQUAL EMYLOYMEN'f AND f�FFI1tMA'1'IVE AC1'ION EMPLOYER��
� ��,� FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No.3067-007Z
, ���Q�L NATIONAL FLOOD INSURANCE PROGRAM Expires December 31,2005
, � ELEVATION CERTIFICATE
Important: Read the instructions on pages 1-T.
SECTION A-PROPERTY OWNER INFORMATION �Fa1�CvmpazyUse��,,�
BUILDING OWNER'S NAME ��q������� � ''��'�� ,
J.M.C.Desi n&Develo ment Cor . ,�_.�f���� � `�. -�-_�����,..,r� -'���
BUILDING STREET ADDRESS(Induding Apt,Unit,Suite,arxi/or Bkig.No.)OR P.O.ROUTE AND BOX NO. Company jJAIC Number 4
�����s��, � �� ����� i
521 Mandalay Avenue �z=F. ,.w�.�..,,,�.����.�,
CITY STATE ZIP CODE
Clearvvater FL 33767
PROPERTY DESCRIPTION(Lot and Blodc Numbers,Tax Parcel Number,l:egal Description,etc.)
Lot 1"Belle Harbor'as rec:orded in Plat Book 125,Page 15 of the Public Records of Pinellas Counry,Florida
BUILDING USE(e.g.,ResidenUal,Norrresidential,Addibon,Acczssory,eta Use a Comments area,ff necessary.)
Multi-story residential
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ❑GPS(Type):
( ##°-##'-##.#/�° or #t�.�) ❑NAD 1927 ❑NAD 1983 ❑USGS Quad Map ❑Other.
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP COMMUNfIY NAME&CO�vTAUNIIY NUN�ER 62.COUMY NAME 83.STATE
City aFCleanarater,Fbrida 125096 Indeper�dar��Cily R
84.MAP AND PANEL 67.FIRM PANEL B9.B,ASE FLOOD ELEVATION(S)
NUA�ER 85.SUFFU( B6.FIRM INDEX DATE EFFECTNEA2EVISED DATE B8.FLOOD ZONE(S) (Zaie A0,use depth d Aooding)
125b960007 D 08/18/1992 0811911991 AE 10&11
B10.Incficate the source of the Base Flood Eleva6on(BFE)data or base flood depih entered in B9.
❑FIS Profile �FIRM ❑Community Determined ❑Olher(Desaibe):
611.Indicate the elevation datum used for the BFE in B9:�NGVD 1929 ❑NAVD 1988 ❑Other(Descnbe):
B12.Is the builcbng 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:�Caistnxtion Dravuings* ❑Building Under Caistnx�or�' �Rnished Construdion
'A new FJevation Cerlificate will be required when constnxiion of the building is complete.
C2.Buildng Diagram Number 7(Seled the building dagram most similar to the build�ng for which this oertificate is being completed-see pages 6 and 7. If no diagram
aocurately reFxesenis the buil�ng,provide a sketch or photograph.)
C3.Elevations—Zones A1 A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR;AWA,ARIAE,AWA1 A30,ARIAH,ARIAO
Complete Items C3:a-i below aa�r�ing to the buil�ng dagram spec;ified in Item C2.State the datum used.If the datum is d'rfferent from the dahim used fa the BFE in
Section B,convert the datum to ihaR used fa the BFE.Show field measuremenis and datum oonversion cak;ulation. Use the space provided or ihe Comments area of
Sec6on D or Section G,as appropriate,to docur�nt ihe datum conversion.
Datum . ConversionlCanments
Elevation reference maric used 5,10 ft Does the elevation reference mark used appear on the FIRM? ❑Yes �No
o a)Top of bottan floor(induding basement or end�ure) 7. 0 ft.(m) m �
o b)Top of next higher floa 17.1 ft.(m) `� �(
o c)Bottan of lowest horizontal stn�ctural member(V zones only) _._�.(m1 0 0 `
o �Attached garage(top of slab) _• _ft•(m) E� �� ����
o e)Lwvest elevation af machinery and/or equipment W" � (� �
serviang the building(Describe in a Comments area) 2.0 ft.(m) �� � �
o fl Lowest�acent(finished)grade(LAGj 6.7 ft.(m) z'0� d Y
o g)H i g h e s t a d j a c e n t(fi n i s h e d)g r a d e(H A G) 7. 4 ft.(m) �
o h)No.of permanent openings(flood vents)within 1 ft.above adjacent grade 2 �
o i)Total area of all perrn�ent openings(fbod vents)in C3.h 31,184 sq.in.(sq.an)
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,B,and C on this certificate represents my best efforfs to interpret the data available.
1 understand fhat any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001.
CERTIFIER'S NAME UCENSE NUMBER
Samuel Mark Beach LS0006261
TITLE COMPANY NAME
Professional Surveyor and Mapper Florida Design Consultants,Inc.
ADDRESS CITY STATE ZIP CODE
3030 Starkey Boulevard New Port Richey FL 34655
SIGNATURE ��'►� �����'�/`'--► I DATE TELEPHONE
08104/2004 (727)849-7588
FEMA Form 81-31,January 2003 See reverse side for continuation. Replaces all previous editions
L �
, IM{'ORTANT: In these spaces,copy the corresponding information from Section A ,Fa�nsuranoe car�ny use,,, ;
BUILDWG STREET ADDRESS(Induding A{�t.,Und,Sui�,andla Bkig.No.)OR P.O.ROUTE AND BOX N0. ' Po�.y IV�ber � �; `����. ..-�
5�1 Mandalay Avenue
. ��-�y STATE ZIP CODE � Canpany NAIC Nurnber
' Cleaiwater FL 33767 '
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community offiaal,(2)insurance agentloompany,and(3)buikJing w�rne�.
COMMENTS
C3.a-Elevation given is bwest garage floor elevation.
C3.b-Elevation given is highest garage floa elevation,Next higher floa FJevaCwn=29.2'
C3 e-Elevation qiven is to the bottom of the elevator shaft _ _ ❑Chedc here if attachments
SECTION E•BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WfTHOUT BFE)
For Zone AO and Zone A(without BFE),oomplete ftems E1lhrough E4. If the Elevation Certificate is inter�d for use as supporting informati�on for a LOMA or LOMRf,
Section C must be completed.
E1.Buildng Diagram Number_(Select ihe buikiing dagram most similar to 1he building fa which ihis cerfificate is being canpleted—see pages 6 and 7. If no diagram aa;urately
represenis the building,provide a sketch or phoiograph.)
E2.The top of the bottom floa(induding base�nent or endosure)of the building is �R.(m)_in.(cm)❑above a ❑below(chedc one)the highest adacent grade. (Us�
natur�grade,'rf available).
E3.For Building Diagr�ns 6-8 with openings(see page 7�,the next high�floor a eleVated floor(elevation b)of the buikling is _ft.(m)_in.(cm)abo�re the highest adjaoert
grade. Complete items C3.h and C3.i on front of form.
E4.The top of the pla�am of machinery andlor equipment senriang the building is _ft.(m)_in.(cm}❑above or ❑below(chedc one)the highest adjaoent grade. (Use
natural grade,'rf available).
E5.Foc Zone AO only: If no flc�od depih number is available,is the top of the bottan floor elevated in accordance with ihe oonmunity's floodplain managernent ordinance?
❑Yes ❑No ❑Unknown. The local official must certify this inforrnatlon in'Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATNE)CERTIFICATION
The property owner or owner's authorized representative who oanpletes Sections A;B,C(Items C3.h and C3.i oniy),and E for Zaie A(without a FEMA-issued or oommunity-
issued BFE)or Zone AO must sign here. The sfatements in Sec��ions A,B,C,and E are co�ect to fhe best of my krawledge.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CADE
SIGNATURE DATE TELEPNONE ,
COMMENTS
❑Chedc here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL) ' •
The local offiaal who is authorized by law a ordinance to administer the canmunii�s floodplain management ordinance can complete Seciions A,B,C(or Ej,and G of�iis Elevation
Certificate. Complete the appl'�cable item(s)and sign below.
G1.�The information in Section C was taken from other documentation that has been sigr�ed and embossed by a licensed surveyor,engineer,or architect who is authorized by state
or local law to certify elevation information. (Ind'icale the source and date o�tt�e elevation data in the Comments area belov�.)
G2.0 A community offidal oompleted Sedion E for a buil�ing bcated in Zone A(without a FEMA-issued or cprnmunity�ssued BFE)or Zone A0. ,
G3.�The fdlowing informa6on(Items G4G9)is provided for community floodpl�n management purposes.
G4.PERMff NUMBER G5. DATE PERMff ISSUED G6.DATE CERTIFICATE OF CO�vPLIANCEIOCCUPANCY ISSUED
G7.This permit has been issued fa:❑New Construction ❑Substan6ai Improvernent
G8.Elevation of as-buifl lowest floa(induding basement)of the buikJing is: _._ft.(m) Datum:
G9.BFE a(in Zone AO)depth of flooding at the buil�ing 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