119 MIDWAY ISLAND �� � �� �� �r! � �' � DERAL;EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3057-0077
r� ` ° NATIOfVAL FLOOD INSURANCE PROGRAM Ex ires Jul 31, 2002
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{� �; i' FE8 1 4 2012 ELEVATIOiV CERTIFICAT�
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.� . �"" ,. I. portanf:_ Read fhe instructions on pages 1 -7.
! �I ARW T ECTION!A-PROPERTY OWNER INFORMATION Fnr�nsurance Company Use -
BUILDING OWNER'S NAME ' Policy'Numbet J �
� Da��s� �2 �- �� - -� - - � -
BUILDING STREET ADDRESS pncluding Ap` Unit,Suite;andlor,Bldg. No.)OR P.O. ROUTE AND BOX NO. Campany NAlC Number
- -� SL :J1� Xs-� = - y --
_ _
C ITY
STATE ZIP CODE
��.��e� �-���.� „���As ��,� �� �o2�D�4 _ 33��-7
PROP RTY DESCRIPT�ON(Lot and BI �+�mbcrs,Tax�arcel Number,Legal Description,etc.) ,�
_�T 3 5 " U�J�'r.3�� )St:�JD �S����5 D� Ci_.c��2�.JkT�2 ,Q 4'7, ��S • �2-�v�
BUfLDIN S�"(e.g.,Residential,rvon-residentiai,Addiuon,Accessory,etc. use�omments seaion ir necessary.)
��s, ���-r-�a �- � ,
LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: ��GPS(Type).
( #,E#°-##'-##.##" or ##.##1###°j ' L�NAD 19:27 Lf NAD 1983 L�USGS Quad Map ��Other:
SECTION B-FLQOD It�SURANCE RATE MAP(FIRM)INFORMATION
61.NFIP COMMUNITY NAME 8 COMMUNITY NUMBER� B2.COU NAME 63.STATE
c,T or c����.��-r��- z o c� � �i ,� ����-s �o2�DA
64.MAP AND PANEL 65.SUFFIX B6.FIRM ItJDEX 67.FIRM PANEL 68.FLOOD 69.BASE FLOOD ELEVATION(S)
NUMBER DATE� EFFECTIVE/REVISED DATE ZONE(S) (Zone AO,use depth of flooding)
I zSoRto-c�7 �c l.� �oG r �9 � Av�vs 8' 99 Z � ��L . �/
B10. Indicate tlie source of the Base Flood Elevation(BFE)data or base floo depfh entered in B9. o m rn� �
�_�FIS Profile �FIRM �_J Community Determined �J Other(Describe): � Z �n �
B11. Indicate the e)evation datum used for the BFE in�B9: (�NGVD 1929 �� NAVD 1988 (J Other(Describe): � Z � N '
612. Is the building located in a Coastal Barrier Resources�System(CBRS)area or Otherwise Proteded Area(OPA)? �Yes � p m O =
rn
Designation Date: a!� N (�
SECTION C-BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) m p O �
C1. Building elevations are based on: �JCoristruction Drawings' �_JBuilding Under Construction' Finished Con � z N �
'A new Elevation Certificate will be required whe�construction of the buifding is complete. � Z p �
C2. Buitding Diagram Number�_(Select the builqing diagram most similar to the building for which this certificate is being cor `� W �
pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) � �
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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 buil;ding diagram specified in Item C2. State the datum used. If the datum is diffF D
the datum used for the BFE in Section B,convertjthe datum to that used for the BFE. Show field measurements and datum cc °�,'
calculation. Use the space provided or the Comrnent$��of Section D or Section G, as appropriate,to document the datum ?�
Datum�1�YD )9Z9 C�nversion/Co ments N
; � ' �
Elevation reference mark used: Does the elevation reference mark used appear on the FIRM? �_�1 �
❑ a)Top of bottom floor(ncluding basement or enclosure) _ O .�ft.(m) �
O b)Top of next higher floor , , " �T ft.(m) `"
❑ c) Bottom of lowest horizontal structural member(V zones only) _��� .�ft.(m) o o �
❑ d)Attached garage (top o f sla b) ; �n•08 .�7" ft•(m) E� �.
❑ e)Lowest elevation of machinery and/or equi mer�f, � . . �d � \ ��'
servicing the building A�C � �• �� •Sft•�m) E� ` 1
O fl Lowest adjacent grade (LAG) $: 1 .�T ft.(m) z'N `�
❑ g)Highest adjacent grade(HAG) �, a .�T ft.(m) � ��
❑ h)No.of permanent openings(flood vents)within 1 ft. above adja /t�qrade � �
❑ i)Total area of all permanent openings(flood vents)in C3h �i sq. m. (sq.cm)
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION
This certification is to be signed and seafed by a land surveyor,engineer, or architect authorized by law to ce�tify elevation information.
I cerfify fhat the information in Sections A, 8, and C on this certificate represents my best efforts fo interpref the data available.
1 undersfand thaf any fa/se stafement may be punish.able by fine or imprisonment under 18 U.S. Code, Section 1001.
CERTIFIER'S NAME J�� L�l LICENSE NUMBER
�C5 ��6J`�
TITLE ���5/ ����� ' COMPANY NAME ���'
J � STAJ� 5�2Y��iJL /�1c .
ADDRESS CITY STATE ZIP CODE3,j`�
1 o t I L�.'rh o 5 � '��4 s�" T (o J s r � C�n 7
SIGNATURE DATE `Z /� 62 TELEPHONE 7Z7- 93_) � ���
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EMA Form 81-31,AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS