211 PALM ISLAND NW U.S.DEPARTMEN7 OF HOMELAND SECURITY ELEVATION CERTIFICATE oMa No. �ssa000s
'Federal Emergency Management Agency Explfes FebfuaN 28,2009
rvaaor,ai Fiood insuranco Proyram Important: Read the instructions on pages 1-a.
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1. Building Owner's Name � �� ��� ��� �G^ PoliCy Number
/-'\
A2. Building Street Address(Including Apt.,Unit,Suite, and/o Bldg.No.)or P.O.Route and Box No. CoFnpany NAIC Number
2► I �4�M ��� nl D N , v�
City G L����A�.�R/ State ('� ZIP Code 337�a7
T- '
A3. Property Descr(ption Lot and Block Numbers,Tax Parcel Number,Legal Descriptlon,etc.)
—!�?� (�°__�_ U�1�-- l�C, L�L�N� �S-�'�4T,ES o-� C���.�vJ/��'ER.
A4. Building Use(e.g.,Residential;Non-Residential,Addition,Accessory, etc.) R�.s r p�,r.!7'�,c�L_
A5. Latitude/Longitude:Lat. Z-7° 59� 0�-•7�� Long. 82°Q-9� I O° Horizontal patum: NAD 1927 NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood inaurance.
A7. Building D(agram Number '-
A8. For a building with a crawl space or enclosure(s),provide: N�A A9. For a building with an attached garage,provide:^/
a) Square footage of crawl space or encloaure(s) sq ft a) Square footage of attached garage `�'1O2 sq ft
b) No.of permenent flood openings in the crawl space or b) No.of permanent flood openings In the attaphe g�rage
enclosure(s)walls within 1.0 foot above adjacent grade walls within 1.0 foot above adJacent grade
c) Total net area of flood openings in AB.b sq in c) Total net area of flood openings in A9.b � sq In
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP Community Name&Community Number B2.County Name B3.State
GU�.�Rw�TE-R �z5oq� PIIJELL�s ���, �
84.Map/Panel Number 85.Suffix B6.FIRM Index B7.FIRM Panel B8.Flood 89.Base Flood Elevation(s)(Zone
�2 I p� /� D I�Z � Date EffectivelRevised Date Zone(s) AO,use base flood depth).
�., 5_� -05 9-03-�03 E, 12'....
810. Indicate the so�rce of the 8ase Flood Elevatlon(BFE)data or base flood depth entered in Item 89.
�FIS Profile t�IRM �Community Determined Q Olher(Describe)
B11. Indicate elevati;on datum used for BFE in Item B9: ❑ NGVD 1929 [NAVD 1988 ❑Other(Describe)
B12. Is the buildfng I'ocated in a Coastal Batrler Resources System(CBRS)area or,r,Otherwise Protected Area(OPA)7 � Yes No � �
Designation Date �CBRS �J OPA � J
� J
SECTI� N C-BUILDING ELEVATION INFQRMATION(SURVEY R�QUIRED) N ro
C1. Building elevations are based on: ❑Construction Drawings; Building Under Constructlon' ❑ Finished Constructlon O �
'A new Elevatfon Certificete will be required when construcUon oh;the building is complete.
C2. 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 C2.a-g� r
below accord(ng to the buildin diagram spec(fied In Item A7. / p, O �
Benchmark Utilized C) O G�-��• � � - Vertical Datum 7'3� 1 �/4"�� �✓ge� � ..�
Conversion/Comments G � L I C� � (n
Check the measurement used. � r
a) Top of bottom floor(Including basement,crawl space,or engiosure floor) �,`►'� Lf�11!feet ❑meters(Puerto Rico only) �
b) Top of the next higher floor �:r� �u feet ❑meters(Puerto Rico only) �
c) Bottom of the lowe,st horizontal structural member(V Zones only) �_0 feet ❑meters(Puerto Rico only) �
d) Attachad garage(top of slab) _�.� � feet ❑meters(Puerto Rico only) z
e) Lowest elevation of machfnery or equipment servicing the b�llding ��Q'(eet �meters(Puerto Rlco only) �
(Describe type of equipment In Comments) �
f) Lowest adJacent(finfshed)grade(LAG) 5,��feet ❑meters(Puerto Rico only)
g) Hlghest adJacent(finished)grade(HAG) +._�,� feet �meters(Puerto Rico only)
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION
This certificaUon(s to be slgned and sealed by a land surveyor,engir�'eer,or architect authorized 6y law to certify elevation ����°'` ''��r,;
informatlon. 1 certify that the(nforinaUon on this Certiflcate represents my best efforts to inferpret the data avallable. ~ � ��, H -� ., �,,,.
!under tand tliat any false stafement may be punlshable by fine or imprisonment under 18 U.S. Code,Section 1001. °� ��`"'���'o�°°•.` ,`�°k;;o ',,
Check here if comments are provided on back of form. �` `N�LJ�'r� �`'��`rA t ��
' A e R
�s3` ��.Mr�� -
��� .� - �-�. ��.� ` _
Certlfier's Name Ucense Number �,;,� �., �'' ��, �, r
Larry L. Evans PLS 4� 2937 :r:� ���=�'��° c�
° � r. � v
Title Company Name r;: •�y(�r3�' yd� ; C "" �
Land Surveyor Evans Land Surveying, Inc. �G? , j� �zb',� ,r,a ' `
Address City State ZIP Code , ��"' • x ° �" �'
>,�•�,. n �. �,kr.", .:
1460 Beltrees Street Suite 9 uned' .
Signature Date �_ �oa Telephone ��Z�� 734-3821 ,�� J�*� ;t�.�°,3
�
''�•,,,�,�.,.>,��.
FEMA Form 81- 1, F ruary 2006 See reverse side for contin,uation. Replaces all previous edit(ons
IMPORTANT: In these spaces, copy the corrgsponding information from Sectlon A. For Insurance Company Use;
BulldiZn.g Street Addr�s(inclul in�pt�nit,SuiN a,n/d�/or Bldg.No.)or P.O.Route and Box No. Policy NUmbbr "
�
Ciry G�����r�� State r, 33ZI�ode Company NAIC-NUrnkier
t"1.�
SECTION D-SURVEYOR, ENGiNEER, OR ARCHITECT CERTIFICATION(CONTINU�D)
Copy both sides of this Elevation Certiflcate for(1)community official,(2)fnsurance agenUCompany,and(3)bullding owner.
Comments C'L� � � i �J� �-l� �XT��ID� �C. CON�.�j��S�aOf� a
---.--
— �2,a) : TFI-�. x��� �z' oT� I-}�Us� is uN,�E.�, CaN sT�u�-�-rn�f PR�s��T�-y.
Signature Date
�"`� 2-z�-�9 �--��
l�Check here if attachments
SECTION -B L ING ELEWATIbN INFORMATION(SURVEY N�T t2EQUIRED) FOR ZON�AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE),complete Items Ei-E5. If lhe CerlifiCate is intended to support a LOMA or LOMR-F request,complete Sections A,B,
and C. For Items E1-E4,use natural grade,if available. Check the measurement used. In Puefto Rico only,enter meters.
E1. Provide elevation informatfon for the following and check the appropriate boxes to show whether the elevation is above or below lhe highest adJacent
grade(HAG)and the lowest adJacent grade(LAG).
a)Top of bottom floor(inciuding basement,crawi space,or enclosure)Is ❑feet ❑ meters ❑ above or ❑below the HAG.
b)Top of bottom floor(including basement,crawl space,or enclosure)is ❑feet ❑meters ❑above or ❑ below the LAG.
E2. For Building Dlagrams 6-8 with permanent flood openings provided in Secti Items 8 andlor 9(see e B of Instructions),the next higher floor
(elevation C2.b in the dlagrams)of the building is r�]feet�meters ❑above or �below the HAG.
E3. Attached garage(top of slab)is �feet Q meters []above or � below the HAG.
E4. Top of platform of machinery and/or equipment servicing the building is _�feet []meters �above or �below the HAG.
E5. Zone AO only: I(no flood depth number is available,is the top of the bottom floor elevated in accordance wfth the community's fioodplain management
ordfnance? ❑Yes ❑No ❑Unknown. The looal oHiclal must certify this fnformation In Sectlon G.
SECTION F-PF20PERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's authorized representative who completea Sections A,B,and E for Zone A(without a FEMA-issued or community-issued 8FE)
or Zone AO must sign here. The statements in 5ectlons A,8, and E are correct to the best of my knowledge.
property Owner's or Owner's Authorized Representative's Name
�ddress City State ZIP Code
_ . _ _
Signature Date Telephone
Comments
❑ Check here If attachment5
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The locai official who is author(zed by.law or ordinance to administer the community's floodplaln management ordlnance can complete Sections A,B,C(or E),
and;G of this Elevation Certificate. Complete the applicable Item(s)and si�gn below. Check lhe measurement used In Items G8.and G9.
G1. � The information In Section C was taken from other documentatf p�n that has been signed and sealed by a lioensed surveyor,engineer,or architect who
is aulhorized by Iaw to certify elevation In(ormatfon. (Indicate thl�source and date of lhe elevatlon data in the Commenta area below.)
G2. ❑ A community officfal completed Section E for a building located(n Zone A(without a FEMA-issued or community-Issued BFE)or Zone AO.
G3. ❑ The following information(Items G4.-G9.)is provided for community floodplain management purposes:
G4.Permft Number G5. Date Permit Issued G6. Da1e Certiflcete Of Compliance/Occupancy Issued
G7.This permit has been Issued for: ❑ New Construction ❑Substanqal Improvement
G8.Elevat(on of as-built lowest floor(lncluding ba�ement)of the bufiding: ❑feet ❑meters(PR) Datum
G9.8FE ar(in Zone AO)depth of flooding at the building site: ❑feet ❑meters(PR) Datum
Locai Of{iciai's Namey� Title
Communit;r Name Telephone
Signature �ate
Comments
❑ Check here if attachments
FEMA Form 81-31, February 2006 Replaces all previous editions
Building Photographs
See Instructions for Item A6.
For Insurance Company Use:
Building Street Address(including Apt.,Unit, Suite, and/or Bldg. No.)or P.O.Route and Box No. Po�icy Number
�� ' � 1S�A,J ,� v' w'
City , State ZIP Code company NAIC Numser '
c..f��h-\r'V���� ��.. . j;; C::.
If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to
the instructions.for Item A6. Identify all photographs with: date taken; "Front�ew" and "Rear View"; and, if required, "Right
Side View" and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page,
following.
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