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(�Q� D�v 2- ELEVATION CERTIFICATE O.M.B. No. 3067-Q077
I��1 1 " �� Expires July 31, 1999
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
: ATTENTION:Use of this certificate does not provide a waivsr of the flood insurance purchase requirement.This form is used only to pro-
vide elevation information necessary to ensure compliance with applicable community floodpiain management ordinances,to determine
the proper insurance premium rate,and/or to support a request tor a Letter of Map Amendment or Revision(LOMA or LOMR).You are not
required to respond to this collection of intormation unless a valid OMB control number is displayed in the upper right corner of this form.
Inatructiona for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMA710N FOR INSURANCE COMPANY USE
BUILDING OWNER'S NAME POLICY NUMBER
STREET ADDRESS(including Apt,Unit.Suite and/or Bldg.Numberj OR P.O.HOUTE AND BOX NUMBER COMPANY NAIC NUMBER
_�(� L l:,�t �
OTHER OESCRIPTt ot and BlocJc Numbers,etc.)
�1 d1 v�r-�- 2�"
CI-T . ' S7ATE ZIP CODE
C�l E�-1r-�,•Z W�tt� -F'br�d�
SECTION B FLOOD INSURANCE RATE MAP(F1RM)INFORMATION
Provide the following trom the proper FIRM(See Instructions): ��
1.COMMUNI7Y NUMBER 2.PANEL NUMBER 3.SUFFIX 4.DATE OF FIRM INDEX 5.FIRM ZONE 6.Bn AO Za�sD.u eEdepN N
12�� 1� ��C� � t1U � 1� �� ��.
7.Indicate the elevation datum system used on the FIRM for Base Flood Elevations(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:�_��.0 feet NGVD(or other FIRM datum—see Section B,Item 7),
SECTION C BUILDING ELEVATION INFORMATION
1.Using the Elevation Certificate Instructions,indicate the diagram number irom the diagrams found on Pages 5 and 6 that best
describes the subject building's reference level 7
2(a).FIRM Zones A1-A30,AE,AH,and A(with BFE). The top of the reference level floor from the selected diagram is at an elevation
of_�.`�Z�� .��feet NGVD(or other FIFiM daturrr-see Section B,Item 7). '
(b).FIRM Zones V1-V30,VE,and V(with BFE). The bottom of the lowest horizontal structural member of the reference level from
the selected diagram,is at an elevation of�J.0 feet NGVD(or other FIRM datum—see Section B,Item 7).
(c).FIRM Zone A(without BFE). The floor used as the reterence level from the selected diagram is ��.iJ teet above� or
below i (check one) the highest grade adjacent to the building.
(d).FIRM Zone AO. The tloor used as the reterence level from the selected diagram is L�.�feet above� or below�(check
one)the highest grade adjacent to the building. If no flood depth number is available,is the building's lowest floor(reference
level)elevated in accordance with the communiry's floodplain management ordinance? � Ye �i No Q Unknown
3.Indicate the elevation datum system used in determining the above reference level elevations:�NGVD'29 i? Other(describe
under Comments on Page 2). (NOTE: lf the elevation datum used in measuring the elevations is different than that used on
the FIRM jsee Section B,Item 7J,then convert the elevations to the datum system used on the F/RM and show the conversion
equation unde�Comments on Page 2.)
4.Elevation reference mark used appears on FIRM: ❑ Yes�No (See Instructions on Page 4)
5.The reFerence level elevation is based on:�actual construction ❑ construction drawings
(NOTE: Use ol construction drawings is only valid if the building does not yet have the re%rence level(loor in place,in which
case this certificate will only be valid lor the building during the course of construction. A posf-construcfion Elevafion Certificate
will be requi�ed once construction is complete.)
6.The elevation of the lowest grade immediatety adjacent to the building is:u���.�i feet NGVD(or other FIRM datum-see
Section B,Item 7).
SECTION D COMMUNITY INFORMATION
1.If the communiry otticial responsibte for verifying building elevations specifies that the reference level indicated in Section C,Item 1
is�ot the'lowest floor"as defined in the communiry's iloodplain management ordinance,the elevation of the building's"lowest
floor'as defined by the ordinance is: ��i.0 teet NGVD(or other FIRM datum—see Section B,Item 7).
2.Date ot the start of construction or substantial improvement •
FEMA Form 81-31,MAR 97 REPlACES ALL PREVIOUS EDfTlONS SEE REVERSE SIDE FOR COt�IT1NUAT10N
SECTION E CERTIFlCATION
� � 7his ceRification is to be signed by a land surveyor,engineer,or architect who is authorized by state or local law to certify elevation
intormation when the elevation inEormation tor Zones A1—A30,AE,AH,A(with BFE),V1—V30,VE,and V{with BFE)is required.
Community officials who are authorized by local law or ordinance to provide floodplain management information,may also sign the
certification. In the case of Zones AO and A(without a FEMA or communiry issued BFE),a building official,a property owner,or an
owner's representative may also sign the certification.
Reference levei diagrams 6,7 and 8-Distinguishing Features—lf the certifier is unable to certify to breakaway/non-breakaway wall,
e�closure size,location of servicing equipment,area use,wall openings,or unfinished area Feature(s),then list the Feature(s) not
included in the certification under Comments below. The diagram number,Section C,Item 1,must still be entered.
1 certify that the information in Sections B and C on this certi(icate represents my best efforts to interpret the data available.
1 undeisfand that any lalse statement may be punishab/e by fine or imprisonment under 18 U.S.Code,Sect;on 100i.
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CERTIFIER`S NRME UCENSE NUMBER(or AKx Seaq
���_1�s� �tvA�4,� I�wlEr'icSAt�1 �f�JStll�r�r�� E�SiN�� �LC..
�sla�,t�„ —lT COMPANY NAME
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DATE PHONE
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��p��ould'�4(B i�Y+aGUe of this Certificate for:1)community ofticial,2)insurance agenUcompany,and 3)building owner.
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SlAB BASEMENT P�ERS,OR COLUIdNS
A V A A V
ZONES 20NES 20NE5 20NES 20NES
AEFEAENCE
LE�EL REFEAENCE
AE�EpE�+CE �E LEYEI
lEvEl ���
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.:.Ci^... �}> B�SE
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B�SE ..;�':/�.'.::'. ..AOJACENT.`;• • � REfEREbCE ELEVATION
i1000 •:"4S`' lEvEt
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ElE'��T� AEfERENCE AOACEMt ';Y,�_
tEVEI G�uOE ;:
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The diagrams above illustrate the points at which the elevations should be measured in A Zones and V Zones.
Elevations for all 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 horizontal structural member.
Page 2
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� A ELEVQ'r'!�N CERTIFlCATE AM����
FcOERAL EMERGiENCY MANACiEM�NT At3�NC`l �'��'31� ��
NATi�NAI Fl.dOD iNSURANCE PROtiRAM
' �Y'TEfn'ION:lJs�oi tNt o�Mticat�doN nat prow��w�lwr ot tha Ifood M�xu�purd�as�tpuinrti�►t Z'Ms btm k usad onty�o pro�
vid��Iw�lion WorMatlon n�assary!o�►au�oompl�nca vrMh tDD�'.sbw�rY�� ob4►�nc�s.to d�t�tmtns
u�
tAt pto�t in�tuattw�smlurn raa,a�dlor te supp�t a rsquost for a L�tat of Map ArtNnOm�nt or�I�OMA or IOMA�.lfbv an not
r.Qu+roa eo n�pond to�i.ooa.etion of�o�m.tbn uN•s.a valla oM9 eo�dol n�x�►bK i�dhplr,yea In m.upp.��iphe com•r o1!hh lorm.
Ih�tn�tdo��ter aerfpN�n�thl�torm dn D�liocmd on tM foltowln�pp�s. .
; 6RCT10NA PiiOPQR?YINtOR1�1A110H ro�1�qtNUMCiCOwwerust
'� YtJN.01N0�OYVti�R'S NAtA! �'OIIC'Y 14N+�/iA
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�. s1'11�"T AD01��(MKI�M�y Aat.�dil,i�M HiObl pd�.N�OM V.O.NOI+TF ANO�OX JitA�MtR OO�YINV MAKt II�JA1�lw
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SECTION p FLOOR 1N8URANCE RATE IYU1P(Fll11fi INFORf�AAT10N
Prot+id�i�w blb�Mnp Irom the prop�r FIfiM(8N In�trucaonal:
1�C01i�ItJNI?Y NI�M t MNlI f�M�� 3.iN��UC �.OAT!OF.'IRM N�piX !.IhlIM lOM� �.�Ati�QiVA�y
�w wv
IZS'7a`}7 OOt$ '�'�� 1 �1 K�
�.�►e.a,..a�►�on�a,R+n��u.�a a+in.F�aM ro�e�•�ooa�w�►ao►a te�: �7 rrc#va� Cioa,.r ce.sare�a+e.aW
e.For zo�A c�v.�Mr.�+o sFE b,a�id.a on tA.FlRM.and tn.p�mn+uM�►nes�saeMMe a e1�E t«C��a�lalnp ate.Y+dlc.t•
a,.�arreun�p+�. �!:Ll_1_L1J.0 h.�Nc�va�a oa,K F�R�aaam-�s..s«�ia+e.n.n,�,
QECTlal�l C oUR.OlNG EI.CiVATlON INFORIAAYtON ._1_ ._... ............,,,.
�n,.._ . .. � � �
1.Uunp It+�Elhrstbn C�lloab In�strtxtlon�i+dkat!1M dtpnm�un�ber�m tM dprams fou�d on Ppe�S�nd 61t�at lxst
dsx�d+�w4}�Ct bW1dMD`�nf�nna hv�1.L.
!(U.RiRf�t Z�na�iJUo►IIE�AH.and A�w1th 8�. Tf►e u�p ol th�nhn�a rov�t Aoor trom 1h�nl�a�d dpnm 1��t sn ekva::on
oi ' � ' ��bN NGVO(a od�K FIRM dalum-sh 5�tion B�h�m�.
(b�.FlAM�onts�t•V�O.VE,and V�whh BFq. '�ht bottom ot ttw low�a hairont�l snucax�l m�mber ot tM nt�nc�It�l trom
�?�: � tM iN�t�d di�p►am�is at an ahv�tion ol(�.1.1.,1J.(J f�t NGVD(a otA�FIRM daNRr-ses S�lion B.Ihm 7).
' t41.FtHM�A(wid�ovt BFq. TMr Iloor uad a t►+�M7�nna levet!rom 1M al�ct�d di�ram b W.L.l het��ow� or
b�bw C 1c�c1t oM� 1M Mph�a!pr�da at�sant to fM Ot�np.
cd�.FlaM=on.Ao, i7►e no«uwd a tM nhre nes teva�trorn u,.:.�ect�!el�pram h t..!_J.0�eec aeow Gi or bebw O�eMdc
�: on��Me NiOA�t�de ad�tw+t to�M bWdkq. It�o flood d�pM�r Is ava�aDl�.ts 1M bu�dinp�s low�at I�oor�nlerona
Mwp�Nwted in socordana wRn�+.oomnwn��Uoodp�sin manp.m.nt o�dtnane�t ❑ ❑ No C unk�own
S.IndoAb tlt��don dalu�n tyst�m w�d in dat�m�ininp fh�sbovt reiecsna Iw�l�Iwalions:�t�t(3VD"s8 � Otfwt�eia�cribs
w+d��Cortxn�nts on A�2�. (NpT�E: p fM�tivatbn dirtwn us�d tn n�ttsurlrg tlM Mrvatfons b�l�rwM than fhat tn�d o�
�M �t p...�+ce►o►�et n.+r 7�eA.�c�onwK a�..a.waoRS ro a�e eatum rystM,�nsd a+tn.Fi►RM ane show u�.ooRwr�..lon
�' • � � �QW(I�f!iXf�(,10A'MIlMIt OA P�.�
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1: . �.Elwatbn nh�+a nnrk u�ed app��on FiRM: ❑ Y�s�No (Sf�1A=��etbnt On PibQ�4)
s.TM nt�nc�k wl N�va6on b Das�d on:�aeNsl consVUetlo� ❑ �on:tructlon drswk�pe .
�MOTE: !1»o�l�7on�1►uctlor�A�awlrmt Ir orrj►vs�d 1!Me d�Rg db�s nd yet Aaw i►N rthrN►C�NwJ Ab0►M phC�.h w�hkh
c�n.a�b c�eN�o�d+.w+r ony es vsia lbr a�.eaaklhp awin�th.c�.or oonsa,aabn. A posr�s�a E/wauon c.rt�pte
�1N b�hquPrud anw censnucEtori!s oonq�Nh.)
���` a.Th��watbn o?It�lowest Qreds lmm�riatsly�actnt to tha buUdup Is:���.1�1 tset NGVD(a other F{AM datum•see
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�' ��CTION D COAAMtlNRY INFORiiAAT10N
�� t.ll l�oortx�xintpr o�Rd�l rospo�slbl�for wrilyinp buadtnp�tw�tioas tO�dRes a�,Et����!n�Iv�sllnd�csbd M S�ctton C.Rem t
;� is not�Q"la�es�tloor`�S dot�ed In Cie conmurr't�s Aoodplah�managemeni a�narxe,�e!�:nrapon ot the b�dld�g,s'loyveat
� � -� !{oo�'as d�lin�d by�M adu+tnc�b: L_L.�..1.1,.r.0 reet MGVD(o�oth�FIRM daturtr-sa�Secdon D.�t�m� � ;�,�,,, ;
�' 2.O�h el tM tl�r!ol oonst�uetion a su�stantlai M�prowm�nt . � i�:� �
,� FEMA fonn tt�t.MAfi 9� RfPLt[FS 1�tt►Rfv1011S EORtOHS SEE REVERSE SIDE Fdt COf�tN�U111'fON
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SEC710N E CER7IFICATION
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� This cMifiption is lo be sipned by a tand surveyor�en�ineer,or erchitect who ls authorized by state or lxal{aw tn cer:iy e�eva�on
ln�otmation wlwn th�elevatlon lnlonnadon for 2on�s At-A30,AE,AH,A(with 8FE),V1-V90,vE�and V(with BF'c)is r�quired.
Cort+muMty oMicials who aro wthoriz�d by local law or o�dinance to provlda floodpiain m�nagemsnt informativ�,maY aQW^e othnn
' _ qtlttfC�tlon, in the casv ot Xon�t AO and A(without a FEMA or communiry istv�d BFE),a buildn9 o�icial,a P��nY
�; owner'3 rop�esentatnn may alio t�On the urti�ication.
";� Retaronc�IwN aa�rams 6,7'and 8•DisUrtquishinp Features-lf the certifier is unabie to certtty to breakaway/non•bro�ksw�y Wa1�,
�febtur!sl=e,�loca�tion ot aervkinp equ�pment,arsa use,watl ope�inps,or un�niahed e�re�Featuro(s).then►Iat the Featuro(s)n�t
M�1ud�d in tht certi6caaon undar Commenta below. 7he daflram number,Secdon C,Itam 1,must sG11 be tntered.
'�� �qrdhr lhat d��Jr►IamatJon In Ss�tlOns 8�nd C on this cert�fiCets represents my best alfoKs to�Rlerpret the data avallable.
± �urrdN�tsnd 1l�Fany/als�statument may be punhhabls by Ane orlmpri�onment under t 8 U.S. Code,Section 100t.'
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CERTITIEItS NAAIE l UCENSE NUMaEfi(a AX�S��t) �, ^
s`t ��"'11f�f4���i� ���IC�J�v � }�v��+l ��1N�4�.. G.is.r
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_ Cop1�s shouid be midt ol this Grtlttcste�or:1)community ofllcfal,2)insur�nee agent/comp�ny�and 3)butleMQ owner.
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Th�di�grama abow illustrats U+e po+�ts st which the elevat�ons shoutd be measured(n A 2ones and V Zonos. ,,
Et�vs�ons for all A 2ones:houtd be measund at the top of the releronca level Iloor. ,
� , Elwatrons for sI1 V Zones shouid be mcasured at!he bottom ol the towest horizonW sWCtunl membpr.
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