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' � �'�� -b Z�7� ELEVATION CERTIFICATE O.M.B. No. 3067-0077
� I FEDERAL EMERC.�ENCY MANACaEMENT AGENCY �p�res July 31, 1999
NATIONAL FLOOD INSURANCE PROGRAM
. : ATTENTION: Use of this certificate does not provide a waivar of the tlood insurance purchase requirement.This torm is used only to pro-
vide elevation information necessary to ensure compliance with applicable communiry floodplain management ordinances,to determine
the proper insurance premium rate,and/or to support a request tor a Letter ot Map Amendment or Revision(LOMA or LOMR).You are not
required to respond to this collection oi information unless a valid OMB control number is displayed in the upper right corner oi this form.
Instructiona tor completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION FOR INSURANCE COMPANY USE
BUIIDING OWNER'S NAME POIICY NUMBER
STREET ADDRESS(Induding Apl,Unit.Suite and/or Bldg.Number)OR P.O.ROUTE AND BOX NUMBER COMPANY NAIC NUMBER
--� SE,acr►��� C�.�;�.�� _
OTHER DESCRIPTIO Lot and Block Numb rs,etc.)
3j�°,. `] uN►�- 2`� _
C�7/y' STATE -` ZIP CODE
�,t14����� �lOr�O'A
SECTION B FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
Provide the foltowing irom the proper FIRM(See Instructions): —"
t.COMMUNITY NUMBER 2.PANEL NUMBER 3.SUFFIX t.OATE OF FIRM INDEX 5.FIRM 20NE 6.BASE FlOOU ELEVATION
(in AO 2ones,use deplh)
�2so� cx�1 t� A� �9 � AL �
7.Indicate the elevation datum system used on the FIRM for Base Flood evations(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:���1�.0}eet 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 from the diagrams found on Pages 5 and 6 that best
describes the subject building's reference level_� .
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
o�'l.'•2� .!.�feet NGVD(or other FIRM datum—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� I 1 I I I,U teet 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 L:—:.�teet above� or
below i. (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 �J.V 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(re(erence
level)elevated in accordance with the community's floodplain management ordinance? ] Yes ❑ No C Unknown
3. Indicate the elevation datum system used in determining the above reference level elevations:�NGVD'29 L: Other(describe
under Comments on Page 2). (NOTE: il the e/evation datum used in measuring the elevations is different than that used on
the FIRM (see Section 8,ltem 7J,then convert the elevations to the datum system used on the FIRM and show the conversion
equation under Comments on Page 2.) r�—�
4. Elevation reference mark used appears on FIRM: ❑ Yes �S No (See Instructions on Page 4)
5.The reFerence level elevation is based on:�actual construction ❑ construction drawings
(NOTE: Use ol const�uction drawings is only valid if the buifding does not yet have the reference level lloor iri place,in which
case this certi�cate will only be valid lor the building during the course of construction. A post-construction Elevation Certificate
will be required once construction is compfete.)
6.The elevation of the lowest grade immediately adjacent to the building is:�.�.0 feet NGVD(or other FIRM datum-see
Section B,Item 7).
SECTION D COMMUNITY INFORMATION
1.If the community official resPonsible for verifying building elevations specifies that the reference level indicated in Section C,Item 1
is not the"lowest floor"as de6ned in the community's floodplain management ordinance,the elevation ot the building's"lowest
floor"as detined by the ordinance is: ��.0 feet NGVD(or other FIRM datum—see Section B,ttem 7).
2.Date of the start ot construction or substantial improvement •
FEMA Form 81-31,MAR 97 REPLA�ES Al1 PREV10U5 EDffIONS SEE REVERSE SIDE FOR COrtTINUATION
: • :;
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 eievation
information when the elevation information for Zones Ai—A30,AE,AH,A(with BFE),V1 V30,VE,and V(with BFE)is required.
Community otficiats who are authorized by local taw or ordinance to provide floodplain management information,may aiso 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. •
Reference level diagrams 6,7 and 8-Distinguishing Features—If the certifier is unable to certify to brea.kaway/non-breakaway wall,
enclosure 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 intormafion in Sections B and C on this ceriificate represents my best effo�ts to interpret the data available.
1 undersfand that any false statement may be punishable by fine or imprisonment unde� 18 U.S. Code,Section 1001.
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CERTIFIEf1'S NAME I LICENSE NUMBER(or AMix Seal) �
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COMPANY NAME " �
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, �°��'.�'�0 ' �. r CITY , STATE ZIP
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��,� .;�Ct�ies s�Jo�r�iq�pe made of this Certificate for:1)community official,2)insurance agent/company,and 3)building owner.
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oN wiTM ON VILES. �
SLAB BASEMENT p1ERS,OR COlUMNS .
A V A A V
20NES ZONES 20NE5 20NES ZONES
AEfEpEMCE qEFENENCE
AE�EpthCE
BASE �EVE� LEYEI
lE•�El i1000
ElEV�nON
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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 iloor.
Elevations tor aIl V Zones should be measured at the bottom oF the lowest horizontal structural member.
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