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� �`�'� ELEVATION CERTIFICATE o.M.s. No. sob�-oon
FEDERAL EMERC.�ENCY MANAGEMENT AGENCY Expires July 31, 1999
NATIONAL FLOOD INSURANCE PROGRAM �
� . AT7ENTION: Use of this certificate does not provide a waivar oi the flood insurance purchasa requirement.This form is used oniy to pro-
� vide elevation intormation necessary to ensure compliance with applicabie community fioodplain 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 information unless a valid OMB control number is displayed in the upper right corner ot this form.
Instructions for compteting this form can be found on the tollowing pages.
SECTION A PROPERTY INFORMATION FoR iNSURnNCe coMPANV use
BUIIDING OWNER'S NAME POLICY NUMBER
STREET AODRESS(Includin9 ApL,Unit,Suite and/or Bldg.Number)OR P.O.ROUTE AND BOX NUMBER COMPANY NAIC NUMBER
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OTHER DESCFIPTION(lb and Block Numbers,ete.)
���1 `I UN� 27
C�N STATE 21P CODE
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SECTION B FLOOD INSURANCE RATE MAP(FIAM)INFORMATION
Provide the tollowing from the proper FIRM(See Instructions): �
1.COMMUNITY NUMBEH 2.PANEL NUMBER 3.SUFFIX 4.DATE OF FIRM INDEX 5.FIRM 20NE 6.BASE FLOOD ElEVA710N
(in AQ 2o�es.use dept�)
I 2�'09�7 c�o1 g, � A �9 1�`3( ��_ Ib _
7.Indicate the elevation datum system used on the FIRM for Base Floo levations(BFE): �NGVD'29 �1 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 BUILDWG ELEVATION INFORMATION
1.Using the Elevation Ce�tificate Inst�uctions,indicate the diagram number trom the diagrams found on Pages 5 and 6 that best
describes the subject building's reference�evel�_ .
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�� .L'�feet NGVD(or other FIFiM daturrt—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 oi� � � � � �.LI feet NGVD(or other FIRM datum—see Section B,Item 7).
(c).FIRM Zone A(without BFE). The floor used as the reference level from the selected diagram is �_i_:.iJ feet above�; or
below� (check one) the highest grade adjacent to the building. .
(d). FIRM Zone AO. The floor used as the reference level from the selected diagram is l�.L.i 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 iloor(reference
level) elevated in accordance with the community's floodplain management ordinance? � Yes ❑ No [ Unknown
3.Indicate the elevation datum system used in determining the above reference level elevations:�NGVD'29 � Other(describe
under Comments on Page 2). (NOTE: ll the elevation datum used in measuring the elevafions is different than that used on
the FIRM (see Section B, Ilem 7J,then convert ihe elevations to the datum system used on the FIRM 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 reterence level elevation is based on:�actual construction ❑ construction drawings
(NOTE: Use oJ const�uction d�awings is only valid if the building does not yet have the reference level lloor in place,in which
case this certi�cate will only be valid/or the building during the course of construction. A post-construction Elevation Certificate
wil!be required once construction is complete.)
6.The elevation of the lowest grade immediately adjacent to the building is:��.� feet NGVD(or other FIRM datum-see
Section B,Item 7).
SECTION D COMMUNI7Y INFORMATION
i.lf the community official responsible for verifying building elevations specifies that the reterence Ieve1 indicated in Section C,Item 1
is not the'lowest tloor"as defined in the community's floodplain management ordinance,the elevation of the building's"lowest
tloor"as defined by the ordinance is: �J.0 feet NGVD(or other FIRM datum—see Section B,Item 7).
2.Date of the start of construction or substantial improvement •
FEMA Form 81-31,MAR 97 REPLACES ALL PREVIOUS EDffIONS SEE RfVERSE SIDE FOR COt�lfINUATION
, � � �
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SECTION E CERTIFICATION
� This certification is to be signed by a land surveyor,engineer,or architect who is authorized by state or local law to certify elevation
information when the eievation information for Zones A1—A30,AE,AH,A(with BFE),V1—V30,VE,and V(with BFE)is requi�ed.
Community otficials 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 community issued BFE),a building official,a property owner,or an
owner's representative may also sign the certification.
Reterence levei diagrams 6,7 and 8-Distinguishing Features—If the certifier is unable to certify to breakaway/non-breakaway wall,
enclosure size,location ot servicing equipment,area use,wall openings,or untinished 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.
I certily that the information in Sectrons 8 and C on this certilicate represents my best eNorts to interpret the data available.
1 understand that any false statement may be punishabfe by fine or imprisonment under f 8 U.S. Code,Section 1001.
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CER7IFIER'S NAME LICENSE NUMBER(or Atfix Seal)
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SITLE . . COMPANY NAME
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� �t�Go�s sl�G�I�,��b�e.,�►iade ot this Certificate tor:1)community otiicial,2)insurance agent/company,and 3)building owner.
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SLAB BASEMEN7 GIERS,OR COIUMNS
A � � A ' V
20NE5 ZONES 20NE5 20NES 20NE5
REFEAENCE qEFERENCE
lEVEI
AE�Epk�+CE BASE IEYEI
F1000
tEv�l EIEVAiqN � .
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MSE ..::%!'+::'..: •AOJ�CENT 4C.`'"%a: AEfERENCE . EIEVATqN
it000 .'••.,:�;• GNADE �'.'.�� IEVEL
E�E•Uiipa AEFEREdCE �OJ�CEMT '- .
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7he 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 ot the reference level floor.
Elevations for all V Zones should be measured at the bottom of the lowest horizontal structural member.
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