2350 SUNSET POINT RD #A _
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U.S.DEPAI�TMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008
Federal Emergency Management Agency Expires March 31,2012
National Flood Insurance Program Important: Read the instructions on pages 1-9.
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1, Building Owner's Name Gary R&Lisa M Goodman TRE,Sunset Pt.Med Clinic Policy Number
A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number
2350 Sunset PoiM Road-Suite A
City Clearwater State FI ZIP Code 33765
A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
Parcel#0&29-16-02844-000-0180
A4. Building Use(e.g.,Residential, Non-Residential,Addition,Accessory,etc.)Non-Residential
A5, Latitude/Longftude:Lat.27d59'24.72"N Long.82d44'19.75"W Horizontal Datum: ❑ NAD 1927 � NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
A7. Building Diagram Number 1A
A8. For a building with a crawispace or enclosure(s): A9, For a building with an attached garage:
a) Square footage of crawlspace or endosure(s) n/a sq ft a) Square footage of attached garage Na sq ft
b) No.of permanent flood openings in the crawlspace or b) No.of permanent flood openings in the attached garage
enGosure(s)within 1.0 foot above adjacent grade n/a within 1.0 foot above adjaceM grade n/a
c) Total net area of flood openings in AB.b n/a sq in c) Total net area of flood openings in A9.b Na sq in
d) Engineered flood openings? ❑ Yes ❑ No d) Engineered flood openings? ❑ Yes ❑ No
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
81.NFIP Community Name&Community Number B2.County Name B3.State
City of Clearvvater/125096 Pineilas FI
B4.Map/Panel Number B5.Suffix B6.FIRM Index 67.FIRM Panel 68.Flood B9.Base Flood Elevation(s)(Zone
12103C/0126 G Date Effective/Revised Date Zone(s) AO,use base flood depth)
09-03-2003 09-03-2003 AE 64.1'
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 69.
❑ FIS Profile � FIRM ❑ Community Determined ❑ Other(Describe)
611. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 � NAVD 1988 ❑ Other(Describe)
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area{OPA)? ❑ Yes � No
Designation Date ❑ CBRS ❑ OPA
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1. Building elevations are based on: ❑ Construction Drawings' ❑ Building Under Construction` � Finished Construction
"A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations-Zones A1-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO. Complete Items C2.a-h
below according to the buiiding diagram specified in Item A7. Use the same datum as the BFE.
Benchmark Utilized Citv of Cleanrvater#I-13Verticai Datum 65.77'
Conversion/Comments NAVD 88
Check the measurement used.
a) Top of bottom floor(including basement,crawlspace,or enclosure floor)63.3 �feet ❑meters(Puerto Rico only)
b) Top of the next higher floor n/a. ❑feet ❑meters(Puerto Rico only)
c) Bottom of the lowest horizontal structural member(V Zones only) n/a. ❑feet ❑meters(Puerto Rico only)
d} Attached garage(top of slab) n/a._ ❑feet ❑meters(Puerto Rico only)
e) Lowest elevation of machinery or equipment servicing the building ❑feet ❑meters(Puerto Rico only)
(Descxibe type of equipment and location in Comments)
� Lowest adjacent(finished)grade next to building(LAG) 62.4 �feet ❑meters(Puerto Rico onty)
g) Highest adjacent(finished)grade next to buiiding(HAG) 62.8 �feet ❑meters(Puerto Rico oniy)
h) Lowest adjacent grade at lowest elevation of deck or stairs,including n/a._ ❑feet ❑meters(Puerto Rico only)
structural support
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor,engineer,or architect authonzed by law to cert�fy elevation 4
information. 1 certify that the informafion on this Cenificafe represents my best efforts to interpret the data availableJ �,�°''�' � �'�
�
understand that any false stafement may be punishab/e by Bne or imprisonment under 18 U.S. Code, Section 1001.� ,-".�,��", � �
Check here if comments are provided on back of form, Were latitude and longitude in Section A provided by a �� '�. r .• � r :
t� ,�'-
licensed land surveyor? � Yes ❑ No ��'�+ � s`" ,���.%�
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Certifier's Name Paul E Hagler License Number 2753 � ' � ��' %�
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Title Pres Company Name Able Land Surveying , ".; F � � . ''` ,�''
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Address 1280 Heather Ri e Blvc: Cit Dunedin State FI ZIP Code 34698 � '• x�a�a.•� };� ,
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Signature DateDS��o ,r�/ Telephone 727-210-0841 a=� r`�� ^� °
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IMPOR7bcNT: In these spaces,copy the corresponding information from Section A. For Insurance Company Use:
Building Street Address(including Apt.,Unit,Suite,and/or Bldg. No.)or P.O.Route and Box No. Policy Number
2350 Sunset Point Road-Suite A
City Cle9rvraterState FI ZIP Code 33765 Company NAIC Nurnber
SECTION D -SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1}community officiai,(2)insurance agenUcompany,and(3)building owner.
Comments �
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Sigrt�tctrE-. r"' ,-, � -�^�,: a;= Date
r, ,a .-,;�w Chedc here if attachments
, �CTf,d,N"E`-H�ii VATION lNFORMATION(SURVEY NOT REQUIRED)FOR 20NE AO AND ZONE A(WITHOUT BFE)
For Zones AO a�J' ' «�u��h�),complete Items E1-E5. if the CeRificate is intended to support a LOMA or LOMR-F request,complete Sections A,B,
and C. For it�tns�,1s��e natural grade,if available. Check ttie measuremeM used. In Puerto Rico only,enter meters.
E1. Provide elevation iniormation for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent
grade(HAG)and the lovrest adjacent grade(LAG).
a)Top of bottom floor(induding basement,crawlspace,or encbsure)is ❑feet ❑meters ❑ebove or�below the HAG.
b)Top of bottom floor(induding basemer�t,crawlspace,or encbsure)is . ❑feet ❑meters ❑above or❑ betow the LAG.
E2. For Building Diagrams B-9 wfth permanent flood openings provided In Sedion A Items 8 and/or 9(see pages 8-9 of Instrudions),the next higher floor
(elevation C2.b in the diagrams)of the building is ❑feet ❑meters ❑above or ❑below the HAG.
E3. Aitached garage(top of slab)is . ❑teet ❑meters ❑above or ❑below the HAG.
E4. Top of platfotm of machinery and/or equipmeM aervicing the building is . ❑feet ❑meters ❑above or�be�ow the HAG.
E5. 2one AO only: If no flood depth number is availabie,la the top of the bottom floor elevated in acco�dance with the community's floodplain management
ordinance? ❑Yes ❑ No ❑ Unknown. The local offiaai must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR OVYNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's autlwrized represeMafive who completes Sedions A,B,and E for 2one A(without a FEMA-issued or commundy-issued BFE)
or Zone AO must sign here. The statements in Sec6ons A,B, and E are corroct to the best of my knowledge.
Proparty Owner's or Owner's Authorized Represer�tative's Name
Address City State ZIP Code
Signature Date Tefephone
Comments
❑C�,j,eck here N attachments
SECTION G-COMMUNITY INFORMATION(OPTlONAL)
The local officiai who ls authorized by law or o�dinance to administer the community's floodplain managemeM ordinance can complete Sectians A,B,C(or E),
and G of this Elevation Certificate. Complete the appikable item(s)and sign below. Check the measurement used in ftems G8 and G9.
G1.❑ The informatio�in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who
is authorized by law to oertify eievation information. (Indicate the source and date of the elevatfon data in the CommeMs area below.)
G2.❑ A communfty official completed Se�tion E for a building located in Zone A(without a FEMA-issued or communRy-issued BFE)or Zone A0.
G3.❑ The following information(Items G4G9)is provided for community floocfplain managemeM purposes.
G4.Permit Number G5. Date Permit Issued G6. Date Certificate Of CompliancelOccupancy Issued
G7. This permit has been issued for: ❑New Construction ❑Sub�antial Improvement
G8. Elevation of as-built lowest floor(inGuding basement)of the building: ❑feet ❑meters(PR)Datum
G9. BFE or(in Zone AO)depth of flooding at the building sfte: ❑feet ❑meters(PR)Datum
G10.Community's design flood elevation ❑feet ❑meters(PR)Datum
Local Official's Name Title
Community Name Telephone
Signature Date
Comments
❑Check here if attachmer�ts
- Building Photographs
See Instructions for Item A6.
For Insurance Company Use:
Building Street Address(including Apt., Unit,Suite,andJor Bldg,No.)or P.O. Route and Box No. Poiicy Number
2350 Sunset Poink Road-Suite A
Clty Clearwater State FI ZIP COd@ 33765 Comparn NAIC Number
If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to
the instructions for Item A6, Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right
Side View" and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page,
following,
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Building Photagraphs
Continuati�n page _
' For Insurance Company Use: l
Buildin Street Address mcludin A Unit, Suiie, and/or Bld No. or P.O. Route and Box No, Poiicy N�mber -�
9 � 9 Pt�, 9• ) I
2350 Sunset Point Road-Suite A
Glfy Cleanvater St8t2 FI ZIP COdB 33765 Company NAIC Number �I
If submitting more photographs than will fit on the preceding page, affix the �dditional photographs below. Identify all
photagraphs with: date taken; "Frant View" and "Rear View°; and, if required, `Right Side View" and "Left Side View."
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For Insurance Company Use:
Building Str�eet Address�ncluding Apt., Unit,Suite, and/or Bldg.No.)or P.O. Route and Box No. Poiicy Number
2350 Sunset Point Road-Suite A
City Clearwater State Fi ZIP Code 33765 Company NAIC Number
If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all
photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View."
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