1370 GULF BLVD � �
' , /.3�Q Gu�f tv�
' �,C tti.a /Qa s A
,6�0 �� - //Y�8
s��w�s�
,�3s�- y.�'��
�((�GK LYU�s
/-
-�'��,,,� �p L car�6
' � ��Q(� � FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM �-�-B. l�Ifl_ 3067-OD77
Expires December 31, 2005
� ELEVATIOGV CERTIFICATE
" .�/Pc�.� �o fA-
� SECTION A-PRGPERTY OWNER INFORIVIATION For Insurance Company Use:
BUILDING OWNERS NAME Policy Number
DALTON SAND KEY,LLC
ncluding Apt.,Unit,Suite,andlor Bldg. No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
1370 GULF BOULEVARD
CITY STATE ZIP CODE
CLEARWATER rL 33767
PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
TnX PARCEL ID NO 19 29 15 00000 140 0500
e.g., es� en�a, on-resi en ia, i ion, ccessDry,e c. se a flmmen area,i nECessar�r.
RESIDENTIAL
LATITllD /LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: GPS(Type):
(##-##-##.##or##.####. ) �NAD 1927 �NAD 1983 �USGS Quad Map �Other.
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP COMMUNITY NAME 8 COMMUNIiY NUMBER B2.COUNTY NAME 63.STATE
CITY OF CLEARWATER 125096 PINELLAS FLORIDA
� 84.MAP AND PANEL B7.FIRM PANEL 69.BASE FLOOD ELEVATION(S)
NUMBER B5.SUFfiX B6.FIR INDER DATE 'tFFECTIVEIREVISED DA�� B8.Fl0IID10NE(S) (Zone AD,LSatlepthpfflaoding)
0014 E 8/18/92 7/2/92 A E 1 1
810,Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in 69.
❑FIS Profile �fIRM �Community Determined ❑Other(Describe):
B1 1.Indicate the elevation datum used for the BFE in B9:�NGVD 1929 �NAVID 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)
Ct.BUilding elevaGons are based on:Q Construction Drawings' �Building Under Construction" �Finished Construction
"A new Elevation Certificate wili be required when construction of the building is complete.
C2.Building Diagram Number 1 (Select the building diagram most similar to the bui!r�ing for which this certificate is being completed-seepages 6 and 7.If no diagram
accurately represents the building,provide a sketch or photograph.)
C3.Elevations-Zones AI-A30,AE,AH,A(With BfE),VE,V1430,V(With BFE),AR,ARA,ARAE,AR/AI-A30,ARlAH,ARAO
Compiete Items C3.-a-i below according to the building diagram specified in liem C2.Slate the datum used.If the datum is different from the datum used for the BFE in
Secton B,convert the tlatum tothat usedior 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 NGVD 1929 ConversioNComments o�R ;,
-- ��7�9? gg,�:
Elevation reference mark used ovEa Does the elevation reference mark used appear on the FIRM? ❑Yes �No _ ;� , � q,-T �
a)Top of boltom floor(including basement orendosure) i�.35 ft.jm) N ��,�`�;�'� `°J*4,�j�°��,
�"�'',* ' „'�' '"
b)Top of next higher floor NA ft.(m) 8 w , � ' �� fM�9,^'
c)Bottom of lowest horizontal structural member(V zones only) NA ft.(m) a� �'n;'�.. �"n .�� �� �
d)Attached garage(top Of slab) 7.0 ft.(m) w o � ��
e)Lowest elevation of machine�and/orequipment �°� ,� , z = � �^��� �� .
servicing the building(Describe in a Comments area) TJA ft.(ml Z.� l.�� � � �4=�!;
f�L�west adjacent(finished)grade(LAG) 5.7 ft.(m) ��, ��• �.'�� 4��,�~
g)Highest adjacent(finished)grade(HAG) 69 ft.(m) � �,��' ' �+.' �.,�', Q�'�*
h)No.of permanent openings(flood vents)within I fl.above adjacent grade NA ft.(m) �' '` A� ` $ '��
i)Total area Of all permanent openings(flood vents)in C3.h sq.in,(sq.cm) '�3��„j ;�,;-�'
SECTION D-SURVEYOR,ENGIPlEER,OR ARCHITECT CERTIFICATIONI
This certification is to be signed and sealed by a land surveyor,engineer,or auchitect authorized by law to certify elevation information.
/certify that the information in Sections A,8,and C on this certificate represents mybest efforts to i�fer�ret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U,S.Code,Section 1001,
CERTIFIERS NAME LICENSE NUMBER
JOSEPH R.GORE,P.L.S. LS5188
TITLE COMPANY NAME
PROJECT'MANAGER HAMILTON ENGINEERING & SURVEYING
CITY STATE ZIP CODE
31 i N.N p A ; 100 - Tam�ra FL 33606
SIGNAT RE DATE TELEPHONE
12/19/03 813-250-3535
� .IMPORTANT: in these spaces,copy the corresponding information from Section A for Insurance Company Use
6UILDING STREET ADDRESS(inciuding Apt,Unit,and/or Bldg.No.)OR P.O.ROUTE AND BOX N0. Policy Number
, 1370 GULF BOULEVARD
" CITY STATE ZIP CODE Company NAIC Number
� CLEARWATER FL 33767
� SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)communily offiaal,(2)insurance agent/company,and(3)building owner.
COMMENTS
Elevations are based on City of Clearwater Benchmark J-02 with a reported elevation of 5.176 feet.(NGVD 1929) Not valid with out
the signature and original seal of a Florida Licensed Surveyor and Mapper.
❑Check here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zone AO and Zone A(without BFE),complete Items EI through E4.If the Elevation Certificate is intended for use as supporting infortriation for a LOMA or LOMR-F,
Sedion C must be completed.
EI.Building Diagram Number-(Seleci ihe building diagram most similar to the building for which this ceRificate is being compleled-see pages 6 and 7.If no diagram accurately
represents ihe building,provide a sketch or photograph.)
E9.The top of the bottom floor(inGuding basement or endosure)of the building is _ ft.(m) in.(cm)[]above or ❑Wow(check one)the highest adjacent grade,(Use
natural grade,If available).
E3.For Building Diagrams 6-8 with openings(seepage 7),ihe next higher Floor or elevated floor(elevalion b)of the building is _it.(m) in.(cm)above the highest adjacent
grade.Complete items C3.h and C3.i on front of form.
E4.The top of the platform of machinery and/or 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 depth number is available,is the top of the bodom floor elevated in accordance with the community's floodplain management ordinance?
❑Yes ❑No ❑Unknown,The local official must certify ihis information in Section G.
SECTION�-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's authorized representative who completes Sections A;B,C(Items C3.h and C3.i onty),and E for Zone A(without a FEMA-issued or communiry-
issued BFE)or Zone AO must sign here.The statements in Sections A,B,C,and E are correct to the best of my knowledge
ROPERTY OWNERS OR OWNERS AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
❑Check here if attachments
SECTION G-COMMUNI"�Y INFORMATION(OPTIONAL)
The local offiaal who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),and G oi lhis Elevation
Certificate.Complete the app►icabfe item(s)and sign below.
G1.Q 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 io certify elevation information,(Indicate ihe source and date of the elevation data in ihe Comments area below.)
G2.Q A community official completed Section E for a building located in Zone A(without a FEMA-issued or community issued BFE)or Zone A0.
G3.Q The following information(Items G4-G9)is provided for community floodplain management purposes.
G4.PERMIT NUMBER G5.DATE PERMIT ISSUED 6
G7.This permit has been issued for: ❑New Construclion ❑Substantial Improvement
GB.Elevation of as-built lowest floor(including 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
COMMENTS
f-1 rtie,.�tie.e:��+«��ti...a.,��
�, � ��� �- FEDERAL EMERGENCY MANAGEMENT AGENCY p_�.B.1�I�_3D67-OD77
�. NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 2005
/� /J �LEVATlO�V CERTlFICATE _
�((�/�c�d /T o SA- -
.---
SECTION A-PROPERTY OWNER 1NFORfVIAT10N For�nsurance Company use:
BUILDING OWNERS NAME Policy Number
DALTON SAND KEY,LLC
ncluding Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
1370 GULF BOULEVARD
CITY STATE ZIP CODE
CLEARWATER FL 33767
PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
TAX PARCEL ID NO 19 29 15 00000 140 0500
e.g., esi en ia, .on-resi en ia, �ion, ccessory,e c_ se a nmmen area,i nE�essar�.
RESIDENT'IAL
LATITllO /IONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: GPS(Type):
(##-##-##.##o�##.###it. ) �NAD 1927 �NAD 1983 �USGS Quad Map �Other.
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP COMMUNITY NAME&COMMUNITY NUMBER 82.COUNTY NAME B3.STATE
CITY OF CLEARWATER 125096 PINELLAS FLORIDA
• B4.MAP AND PANEL 87.FIRM PANEL 69.BASE FLOOD EIEVATION(S)
NUMBER BS.SUFFIX B6.FIRM1 EX.DATE EFFECTIVEIREVISE�DP,i� B9.F1011DZDNE(S) �ZoneAD,LSetleplhni(laoding)
0014 E 8/18/92 7/2/92 AE 11
810,Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in 69.
❑FIS Profile �FIRM ❑Community Determined ❑Other(Describe):
Bi 1.Indicate the elevation datum used for the BFE in 69:�NGVD 1929 �NAVID 1988 ❑Other(Describe�:
612.Is the building located in a Coastal Barrier Resources System(CBRS)area or Othenvise Protected Area(OPA)? ❑Yes �No Designation Date
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1.BUilding elevations are based on:Q Construction Drawings' �8uildin�Under Construction" �Finished Construction
'A new Elevation Certificate will be required when construction of ihe building is complete.
C2.Building Diagram Num6er 1 (Select the building diagram most similar to the building for which this cerfificate is being compleied-seepages 6 and 7.If no diagram
accurately rep�esents the building,provide a sketch or photograph.)
C3.Elevations-Zones AI-A30,AE,AH;A(With BFE),VE,V1430,V(With BFE),AR,ARA,ARAE,AR/AI-A30,AR/AW,ARAO
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
Secton B,convert the datum tothat usedinr 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 NGV�t929 ConversionlComments o�R �•
�3 �m �qF�
Elevation reference mark used ov�R Does the elevation reference mark used appear on the FIRM? ❑Yes �No ';�!}� �1 r
a)Top of boflom floor(including basement orenclosure) -�6.3� fl.{mj � ,;' t�ro`��� � b��� { �,
b)Top of nexl higher floor NA ft.(m) w a�?� � r�. �; �
��. ^;
c)Boflom of lowest horizontal sUuctural member(V zones oniy) NA. ft.(m) a�� "" + +`' �;` �.; .�� '
d)Attached garage(top Of slab) 7.0 ft.(ml w �' ���, ; 4 ` ,��
v�� , ' i � � � :
e)Lowest elevation of machiner�and/arequipment u`,,�n r, .�
� y kY
servicing the building(Describe in a Comments area) NA ft.(m) z��� � t z� `' �� �,
f�lovuest adjacent(finished)grade(LAG) 5.7 ft.(m) �'��, �"� •r� � C� p �•
g)Highest adjacent(finished)grade(HAG) 6.9 fL(m) �t`,' �'� ;� �K, ; ,�. „,' ;
h)No.of permanent openings(flood vents)within I ft.above adjacent grade H� {t.1�� � � '� ,,$���1�r]Qf6�'
i)Total area Of ail permanent openings(flood vents)in C3.h sq.in,(sq.cm) � " � °,��� ,'�'�
,
SECTION.D.-SURVEYOR,ENGINEER,.OR ARCHITECT CERTIFIGATIOPI •;i`•t'
�_
This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation info�mafion
/certify that the information in Sections A,8,and C on fhis certificate cepresents mybest efforts to infer�ref the dataavailable.
/understand that any false statement may be punishable by fine or imprisonment under 18 U, S.Code,Section 1001,
CERTIfIERS NAME ` UCENSE NUMBER
JOSEPH R.GORE,P.L.S. LS5188
TITLE COMPANY NAME
PROJECT MANAGER HAMILTON ENGINEERING& SURVEYING
CITY STATE ZIP CODE
31 i N.N A ; -lU0 Tampa FL 33606
SIGNAT RE DATE TELEPHONE
12/19/03 813-250-3535
, IMPORTANT: in these spaces,copy the corresponding information from Section A for Insurance Company Use
,�BIiILDING STREET ADDRESS(inciuding Apl,Unit,and/or Bldg.No.)OR P.O.ROUT�AND BOX N0. Policy Number
1370 GULF BOULEVARD
CITY STATE ZIP CODE Company NAIC Number
,�CLEARWATER FL 33767
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CEf2TIFICATION(CONTiNUED)
Copy both sides of this Elevation Certificate for(1)community offiaal,(2)insurance agent/company,and(3)building owner.
COMMENTS
Elevations are based on City of Clearwater Benchmark J-02 with a reported elevation of 5.176 feet.(NGVD 1929) Not valid witll out
the signature and original seal of a Plorida Licensed Surveyor and Mapper.
. � ❑Check here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zone AO and Zone A(without BFE),complete Items EI through E4.li the Elevation Certficate is intended for use as supporting information for a LOMA or LOMR-f,
Seclion C must be completed.
EI.Building Diagram Number-(Seleci ihe buiiding diagram mosi similar to lhe building for which this certificate is being completed-see pages 6 and 7.If no diagram accurately
represents the building,provide a sketch or phoiograph.)
E9.The top of the bottom floor(including basement or endosure)of the building is_ft.(m) in.(cm)Q above or ❑Wow(check one)the highest adjacent grade,(Use
natural grade,If availa6le).
E3.For Building Diagrams 6-8 with openings(seepage 7),the next higher floor or elevated Boor(elevation b)of the building is fl.(m) in.(cm)above the highest adjacent
grade.Complete items C3.h and C3.i on iront of form.
E4.The top of the pla8orm ot machinery and/or epuipment serviang the building is ft.(m) in.(cm)�above or�below(check one)the highest adjacent grade.(Use
naturai grade,i(available).
E5.For Zone AO only:If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's Floodplain management ordinance?
❑Yes ❑No ❑Unknown,The local official must certify this information in Section G.
SECTION F-PROPER7Y OWNER(pR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's authorized representative who completes Sections A;6,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,B,C,and E are correct to the best of my knowledge
ROPERTY OWNERS OR OWNERS AUTHORIZED REPRESENTATIVE'S NAM[
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
❑Check here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local offiaal who is authorized by law or ordinance to adminisler the community's floodplain management ordinance can complete Sections A,B,C(or E),and G of this Elevalion
Certificate.Complete the applicable item(s)and sign below.
G1.Q The information in Section C was laken irom other documentation that has been signed and embossed by a licensed surveyor,engineer,or architect who is authorized by state
or local law to certity elevation information,(Indicate the source and date of the elevation data in ihe Comments area below.)
G2.Q A community official completed Section E for a building located in Zone A(without a FEMA-issued or community issued BFE)or Zone A0.
G3.Q The following information(Items G4G9)is provided for community floodplain management purposes.
G4.PERMIT NUMBER G5.DATE PERMIT ISSUED 6
G7.This permit has been issued far: ❑New Const�udion ❑Substantial Improvement
G8.Elevation of as-builf iowest floor(induding basement)of the building is: ft.(m) Datum:
G9.BFE or(in Zone AO)depth of flooding at the building site is: fl.(m) Datum:
LOCAL OFFICIAL'S NAME T1TLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
�
nrtie,.�tie.e:r����..ti..,e.,<<
.� # c��f- �vS�
��
• FEDERAL EMERGENCY MANAGEMENT AGENCY O.MB. No. 3067-DD77
NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 2005
�LEVATtON �ERTlFICATE
SECTION A-Pf20PERTY OWNER INFORf�lATION For Insurance Company use:
BUILDING OWNERS NAME Policy Number
DALTON SAND KEY,LLC
BUILDING STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
1370 GULF I30ULEVARD
CITY STATE ZIP CODE
CL�ARWATER FL 33767
PROPERTY DESCRIPTION(lot and Block Numbers,Tax Parcel Number, Legal Description,etc.)
T�X PARCEL iD NO 19 29 15 00000 140 OSUO
e.g., esi en ia, on-resi en ia, �ion, ccessory,e . se a ommen area,i oE�essar�.
RGSIDENTIAL
LATITUD /LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: GPS(Type):
(##-##-##.##or##.#7dk#. ) �NAD 1927 �NAD 1983 �USGS Quad Map �Other.
SECTION B-FLOOD INSURANCE RATE MAP(FIRM) INFORMATION
61.NFIP COMMUNITY NAME 8 COMMUNITY NUMBER 82.COUNTY NAME 63.STATE
CITY OF CLEARWATER 125096 PINELLAS FLORIDA
B4.MAP AND PANEL 67.FIRM PANEL 69.BASE FLOOD ELEVAT�ON(S)
NU BER 95.SUFFIX B6.FIRM INDEX.DA E EFFECTIUEIREUIS6D DA�� B8.Fl00DZONE(S) (Z.oneAD,lise�lepth�i(I�flding)
00 l4 E 8/l 8/92 7/2/92 AE 1 1
810,Indicate the source oi the Base Flood Elevation(BFE)dala or base flood depth entered in B9.
❑FIS Profile �FIRM ❑Community Determined ❑Other(Describe):
B1 1.Indicate the elevation datum used for lhe BFE in B9:�NGVD 1929 �NAVID t988 ❑Other(Describe):
612 !s the building located ic a Coastal Barrier Ras?!irces System(CBRS)area or Olhenvise Protecled Area(OPA)? ❑Yes �No Designation Date
-- — ._
_ --_ . _ _
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1.Building elevations are based on:Q Construction Drawings" �Buiiding Under Construction" �Finished Construction
*A new Elevation Cerfificate will be required when consfruction of the building is complele.
C2.Building Diagram Number 1 (Select ihe,building diagram most similar lo the building for which ihis certi5cate is being complefetl-seepages 6 and 7.If no diagram
accurately represents the building,provide a sketch or photograph.)
C3.Elevafions-Zones AI-A30,AE,AH,A(With BfE),VE,V1430,V(With BFE),AR,ARA,ARAE,AR/AI-A30,AR/AN,ARAO
Compiele Items C3.-a-i below accortling to the building diagram specified in item C2.State ihe datum used.if the datum is different from the datum used for the BFE in
Secion B,convert the dafum tothat usedfor the BFE.Show field measurements and datum conversion calculation,Use the space providetl or lhe Comments area of
Section D or Section G,as appropriate,to document the dalum conversion.
Datum NGVD i929 ConversioNComments�v�R
Elevation reference mark used ovea Does the elevation reference mark used appear on the FIRM? ❑Yes �No
a)Top of bottom floor(incW�ing basement or�ndosure) ab'35 #i.{m) � �
b)Top af next higher floor NA ft.(m) � g
c)Bottom of lowest horizontal structural member(V zones only) NA fL(m) °° � �
d)Attached garage(top Of slab) 7.0 fi.(m) w �
e)Lowest elevation of machiner�and/ore4uipment � �' � �
servicing the buiiding(Describe in a Comments area) NA ft.(m) � G j ' �
z� I �
f�Lowest adjacent(finished)grade(LAG) 5.7 ft.(m) �;°' �
g)Highest adjacent(finished)grade(HAG) 6.9 ft.(m) v
h)No.of permanent openings(ilood vents)within I ft.above adjacent grade NA fi.(m) '� -� , 1�8-12/l 9103
i)Total area Of aii permanent openings(flood venls)in C3.h sq.in,(sq.cm) ��
SECTION D-SURYEYOR,ENGINEER,OR ARCHITECT CERTIFICATIOIa ��
i
This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation information.
/certify that the information inSections A,8,and C on this certificate represents my�est efforts#o aafer{�ret the dataavailable.
/understand that any false statement may be punishable by fine or imprisonment under 18 U, S.Code,Section 1001,
CERTIFIERS NAME LICENSE NUMBER
JOSEPH R. GORE,P.L.S. LSSl88
TITLE COMPANY NAME
PROJECT MAN GE HAMILTON ENGINEERING & SURVEYING
e` CITY STATE ZIP CODE
311 N. ew o ; i P100 Tampa FL 33606
SIGN URE DATE TELEPHONE
F 12/19/03 813-250-3535
r
�; ..
�
.,. ,
.
• � INiPORTANT: In these spaces,copy the corresponding information from Section A For Insurance Company Use
' BUILDING STREET ADDRESS(Including Apt,Unit,and/or Bldg.No.)OR P.O.ROUTE AND BOX N0. Policy Number
1370 GULF BOtILEVARD
CITY STATE ZIP CODE Company NAIC Number
CLLARWA1'LR FL 33767
SECTION D-SURVEYOR,ENGINEER,OR ARCiiITECT CEf2TIFICATION(CONTiNUED)
Copy both sides of this Elevation Certficate for(t)community official,(2)insurance agenUcompany,and(3)building owner.
COMMENTS
Elevations are based on City of Clear�vater Benchmark J-02 with a reported elevation of 5.]76 feet.(NGVD 1929) Not valid with out
the signature and original seal of a Florida Licensed Surveyor and Mapper.
❑Check here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zone AO and Zone A(without BFE),complete Items EI through E4.H lhe Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F,
Section C must be completed.
EI.Building Diagram Number-(Select the building diagram mosf similar to the building for which this cerlificaie is being compleled-see pages 6 and 7.If no diagram accurately
representsthe building,provide a sketch or photograph.)
E9.The top of the bottom floor(including basement or endosure)oi the building is_ft.(m) in.(cm)Q above or ❑Wow(check one)the highest adjaceni grade,(Use
natural grade,N available).
E3.For Building Diagrams 6-8 with openings(seepage 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 platform of machinery andlor equipment serviang the buiiding is fl.(m) in.(cm)Q above or�below(check one)the highest adjace�t grade.(Use
natural grade,it available).
E5.For Zone A�only:If no flood depth number is available,is the top of the botlom floor elevated in accordance with the community's floodplain management ordinance?
❑Yes ❑No ❑Unknown,The local official must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR i;WNER'S REPRESEiJ7ATIVE)CERTIFICATION
The property owner or owners authorized representative who completes Sections A;B,C ptems 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,B,C,and E are correct to the best of my knowletlge
PROPERTY OWNERS OR OWNERS AUTHORIZED REPRESENTATIVE'S NAh4E
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
❑Check here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local offiaal who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),and G of this Elevation
Certificate.Complele the applicable item(s)and sign below.
G1.❑The information in Section C was taken from other documentation ihat has been signed and embossed by a licensed surueyor,engineer,or archifect who is aufhorized by state
or local law to certify elevation information,(Indicate the source and date of the elevaiion data in lhe Commenls area below.)
G2.Q A community offiaal completed Sedion E for a building locaied in Zone A(without a FEMA-issued or community issued BFE)or Zone A0.
G3.Q The following information(Items G4G9)is provided for wmmunity floodplain management purposes.
G4.PERMIT NUMBER G5.DATE PERMIT ISSUED
G7.This permit has been issued for: ❑New Construction ❑Substantial Improvement
G6.Efevation of as-built lowest floor(incfuding 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
COMMENTS
I-1 rti.,,.�ti.,.,,:f,�iti,,.ti...,,.,��