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G ELEVATION CERTIFICATE O.M.B. No. 3067-0077
' �� l��Z�� FEDERAL EMERC�ENCY MANACaEMENT AGENCY �p�res July 31, 1999
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NATIONAL FLOOD INSURANCE PROGRAM
• A77ENTION: Use of this certificate does not provide a waivar of the tlood insurance purchase requirement.This torm is used only to pro-
� vide elevation iniormation necessary to ensure compliance with applicable commun'rry floodplain management�ordinances,to determine
the proper insurance premium rate,and/or to support a request for 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 oi this form.
Instructiona for completing this form ca�be found on the following pages.
SECTION A PROPERTY INFORMA710N fOR INSURANCE COMPANY USE
BUILOING OWNER'S NAME POIICY NUMBER
STREET ADDRESS(Including Apt,Unit,Suite andlor Bldg.Number)OR P.O.ROUTE ANO BOX NUMBER COMPANY NAIC NUMBER
�o SE� � '� ���rc��
OTHER DESCRIPTIO (Lot andiB o 2�bers,e4e.)
3�a � �r�
C�TM STATE ZIP CODE
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SECTION B FLOOD INSURANCE RATE MAP(FlRM)INFORMATION
Provide the tollowing from the proper FIRM(See Instructions):
t.COMMUNITY NUMBER 2.PANEL NUMBER 3.SUFFIX 4.DATE OF FIRM INDEX 5.FIRM ZONE 6'B�AO 2o�s�,use depth)N
12505� oo If3 � �� I�1 9 �-1� 10
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 INFORMA710N
1.Using the Elevation Certificate Instructio.ns,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 A7-A30,AE,AH,and A(with BFE). 7he top of the reference level floor from the selected diagram is at an elevation
of`�.''•� �9 .IU 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 ot the reterence level from
the selected diagram,is at an elevation of���.0 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 �:.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�.i_:feet above� or below�{checfc
one)the highest grade adjacent to the building. If no flood depth number is available,is the building's lowest floor(reference
fevel)elevated in accordance with the community's floodplain management ordinance? � Yes �' No C Unknown
,� NGVD'29 i' Other describe
3.Indicate the elevation datum system used in determining the above reference level elevations: �
under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is diNerent than that used on
the FIAM (see Section 8,ltem 7J,fhen convert the elevations to fhe datum system used on the F1RM an�show the conversion
equation under Comments on Page 2.)
4.Elevation reference mark used appears on FIRM: ❑ Yes�No (See InsVuctions on Page 4)
5.The reference level elevation is based on:� actual construction ❑ construction drawings
(NOTE: Use o1 construction drawings is only valid if the building does not yet have the re(erence level floor in place,in which
case this certircate will only be valid/or the building during the course of construction. A post-construction Elevation Certificate
wil!be required once consUuction is complete.)
6.The elevation of the lowest grade immediately adjacent to the building is: l���.�i feet NGVD(or other FIRM datum-see
Section B,Item 7).
SECTION D COMMUNITY INFORMATION
1.If the community official responsible tor verifying building elevations specifies that the reference level indicated in Section C,Item 1
is not the'lowest tloor"as detined in the community's floodplain management ordinance,the elevation of the building's"lowest
iloor"as defined by the ordinance is: �J__�_�__LJ.0 feet NGVD(or other FIRM datum—see Section B,Item 7).
2.Date of the start oi construction or substantial improvement •
FEMA Form 81-31,MAR 97 REPtA�ES ALL PREVIOUS EDITIOtJS SEE REVERSE SIDE FOR COMINUATION
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' SECTION E CERTIFICATION
' � This certitication 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 elevation intormation for Zones A1—A30,AE,AH,A(with BFE),V1—V30,VE,and V(with BFE)is required.
Community officials who are authorized by Iocai 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 properry owner,or an
owner's representative may a�so sign the certification.
Reference levei diagrams 6,7 and 8-Distinguishing Features—if the certifier is unable to certify to breakaway/non-breakaway wall,
enciosure 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.
!certity that the information in Sections 8 and C on this certificate represents my best eNorfs to interpref the data available.
f undeistand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code,Section 1001.
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'�' � � • 8 1`nade of ttii�Certificate for•1 community official,2)insurance agenUcompany,and 3)building owner.
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COMMENTS:. a � • �?'`�
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ON WttH ON PILES,
SLAB BASEMENT PIERS,OR COLUMNS
A V � A V
20NE5 ZONES IONES ZONES ZONES
AE�EAENCE REFERENCE
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The diagrams above illusuate the points at which the elevations should be measured in A Zones and V Zones.
Etevations for aIl A Zones should be measured at the top oi the reference level floor.
Elevations for all V Zones should be measured at the bottom ot the lowest horizontal structural member.
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