18675 US HWY 19 N #248 , , FEDER/�L EMERGENCY MAN�AGEIVI�N7 AGENCY O.M.f3. IVo. 3067-0077
1��DB t L�[-��Vl.� NATI(3NAL FLOOD INSURAIVCE PROGRAM Expires December 3'i, �.005
oP�� uh1A��-- ELE1�''ATIOIV CEF�TI�ICATE
3 � 2���( Im or�ant: Read the instructions an a es 9 -7.
_ SECTIOIV A-PROP�RTY OWNER INFORCVIATION For Insurance Gompany Use;
i J1NG OWNER'S NAME Pplicy Nwnbsr
P lm '
BUtLDING STREET ADDRESS(lnciuding Aqct�.lnit,Suite,an or Bldg.No.)OR P.O. ROUTE ANU BOX NO. Company NAIC IVumber
1 8675 I�s 1 9 Nnrth Z�t5
CITY STATE ZIP CODE
�1 P�rs:,ater Florida ���64
PROPERTY DESCRiATiON(Lot and Block lVumbers,Tax Parcel IVumher,Lagal Description,etc.)
BUILDiNG USE(e.g.,Res ent�al, on-resi entia, d ,Accessory,etc. Use a Comments area,if necessary.)
Res i dc�nt�31
LATITUDElLONGlTUDE(OPT�ONAL) FiORIZONTAL DATUM: SOURCE: �_�GPS(Type):
( ##°-##'-##,##" or #�`.#�###°) �,�NAD 1927 �_�NAD 1983 �_�USGS Quad Map �_�Other
SECTI�IV B-FLOOD INSURANGE RATE 141AP(FIRM)INFORMATION - �
B7. fVFiP COMMUNITY NAME&COMMUNITY NUMBER B2.COUNTY NAME H3.STATE
City of Clearwater 1 25(19ti Pinellas F1 nri r�a •
B4.MAP AIVD PANEL B5.SUFFIX B6.FIRM INDEX B7.FIRM PANEL B8, FLOOD B9.BASE FLOOD ELEVATION(S)
I iJiiiv1Estk ` -r��rr.�nr�/S..c..M^-'�r- �^"J��S; /Tnn�qn,��SR r�sprh of flandingl
ur��E '-:i=cC,av"+.�.! .'�:� -
125096 0128 G � Se t. 3 2003 Se t. 3 0 9
B70. indicate the source of the Base Flood Elevation (Bf=E)data or base flood depth entered in B9.
�� F!S Profile ��� FIRM �_�Community Qetermined �,_..(Other(Describe):
B11. Indieate the elevation datum used for the BFE in B9: ��� NGVD 1929 {�,�NAVD 1988 �,�Other(Describe):
B�2. Is the building located in a Coastal Barrier Resources Systsm(GBRS)area or Otherwise Pratected Area (OPA)? �T�Yes �.� Na
Designation�Date:
SECTIQN C-BUII.pING ELEVATIDN INFORMATION(SURVEY REQUIRED)
C'I. Suiiding elevations are based on: �_�Construction Drawings' ��.�Building Under Gonstruction* (x�Finished Construction
new Elevation Certificate wili be required when construction of the building is complete.
C4. �ilding Diagram Numbex $ (Select the building diagram most similar to the buiiding for which this certificate is being completed-see
pages 6 and 7. Ifi na diagrarn accurately represents the building,provide a sketch or photograph.)
C3. Elevations-Zones A1-A30,AE, AH,A(with BFE), VE,V9-V30,V(with BFE),AR,ARIA,AR/AE,AR/A1-R30, AR/AH,AR/AO
Complete ltems C3.a-'s below according to the building diagram specified in Item C2. State the datum used. If the datum is different from
the datum used for the BFE in Section B,convert ttte datum to tMat used for the BFE. Show field measurements and datum conversion
calculation. Use the space provided or the Comments area Qf Section D or•Sectioh G,as appropriate,to document the datum conversion.
Datum NAVD�fi CanversioNComments NGVD 29 O 0 AO fPPt' - NAViI gg��ee��
Elevation reference mark used Dogs the elevatfon reference mark used appear on tt��d�r,�,�;�„J Yes �x� No
� a) To of bottom floor(includin basement or enclosureJ 5 ..Z ft.(m) •� �,< ;�w , ,
P 9 y ` �."�� ,,�.�;�a��.,'�,.�.�
�l b) Top of next higher floor 9 .?ft.(m) � „ `,"��' '�'� ' " � .��� ,
❑ c) Battom of lawest horizontai structural member(V zones only) N/A _.ft.(m) :�� '+�,. � � � �':
—ft•(m) � ��.• �
❑ d} Attached garage (top of slab) �I1I/R ��--
�1 ej Lowest elevation oi mdc'r�inery a�idio;equiNtnent -� � = �, ;.� ' .
servicing the huiiding (Describe in a CommenCs areaJ 9 •�Q.ft•(m) �� ; --„ ` �, `=
� � Lowest adjacent(finished)grade(LAG) 5 ._Z_.ft.(m) z� ;�'�,��,� ''�'` �'"'�`�� ,�f"�
� g) Highest adjacent(finished)grade (HAG) 6 .�ft.(m) � '���,�� � ��� ���.°•`
❑ h No.of �rmanent o enin s flood vents wlthin 1 ft,above ad'acent grade n � ;w���,��%n �� �,,�n�
) A p 9 ( ) J ,,r� ,� � ,,�
Cl i)Totai area of ali permanent oj�'enings(flood vents) in C3.h g sq.in. (sq. cm) �� �'. �'�
. ,�' 1 � D•-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION
This certification is tp;be sf�ie hd 9ea! y.�•land surveyor,engineer,or architect authorized by law to certify elevation infarmation.
!certify that the infcr�rx�ti 'n� �� ari�GG on this certificate represents my b�st efforts to interpret the data available.
. . � �� � �;.
I undeFStand that an��t,�a S � eni ma , e J ,rushable b frne or im risonment unde�78 U.S. Code, SecUon 1001.
CERTIFIER'S NAME ... �µ.` : ' �.;f" :`�;« LICENSE NUMBER LS 4086
81 .A�'`'� kG
TITLE . "� � COMPANYNAME Michael Baker Associates
�,and•� �r� �o � ,r �� STATE Z3 CODE
�.ESS '� +.� ° � •'.. CITY ,
��C�� �S. °prd '�ve. Tar on S rin
SIGNATURE "�., "� ,�,��` DAT� TELEPHONE
�, ; ,; August 1 0, 2004 727-938-5026
__ ____ ___ ___
1tViPO�TAN.T•: in these spaces,copy the corrisponding iniormation fror��Sectiori A. t=or�nsuran�e i:orr�par�y u���
6WLDtnIG STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bidg.No.)OR P,O. ROUTE AND QOX NO. Policy Number
18675 US 19 North
CI7Y S'fA7E ZIP COOE Company NAtC Number
C�earwater Florida 33764
SECTION b-SURVEYOR, EIVGIN�ER, OR ARCHITECT CERTIFICATION {CONTINUED)
Copy both sides of this Elevation Certificate for(1)community official, (2)insur�nce agenticompany, and (3) building owner. �
COMMENTS �� �i
Elevations 7 081 feet NGVD29 converted tQ Plevation- 6 1 �i? fPPt'
^ tvAVD s� ..��eu g-�f S'�,��•�Q� I�lo3ea ixe6
C3e Air ConditiOnei'ZTCK C-�' S4o�cQ �.,� c��Q� I—1 Check here if attachments_
SEC710N E- BUlLD1NG ELEVATION 1NFOFiMATION (SURVEY NOT F2EQUIRED) FOR ZONE/a0 AND ZUIVE A(WITHOUT BFE)
For Zone AO and Zone A(without BFE), compiete Items E1.through E5. if the Elevation Gertificate is intended for use as supporting
information for a LOMA or L�MR-F, Section C must be completed.
E1. Building Diagram Number {Select the building diagram most similar to the building for which this certificate is being completed-
see pages 6 and 7. If no diagram accurately represents the building,provide a sketch or photograph.)
E2. The top of the bot�om floor (including basement or enclosure)of the building is I—I—I�• �m� I--I—I �n. (cm)�_� above or �_� below
(check one)the highest adjacent grade. (Use natural grade, if available.)
E3. For Building Diagrams 6-8 with openings(see page 7),the next higher floor or elevated floor(elevation b) of the building is
I-1—I ft• �m) I—I-.-I�n. (cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form.
�4. T�a top af the pla:form cf much:r.ery ardl�r eq!ii�rnent servicing ihe buildinp is �_�^I ft. (m) �,._,�_�in. (cm} �_� above or�_� below
(check one)the highest adjacent grade. (Use natural grade, if available.)
E5. For Zone AO only: li no flood depth number is available,is the top of the bottam floor elevated in accordance with the community`s
floodplain manaqement ordinance?� ( Yes � � No � I Unknown The local official must cartify this information in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property owner or owner's authorized representative who completes Sections A, B,C (Items C3.h and C3.i only), and E for Zone A
(without a FEMA-issued or community-issued BFE)or Zone AO must sign here. The statements in Sections A, B, C, and E are correct to
the best ofm kno�vled e.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CfTY STATE ZIP CODE
SIGNATURE aATE TELEPHONE
COMMENTS
�_� Check here if attachments
� SEGTI�N G-COMMUNITY 11VFORMATIDN (�PTICINAL)
The local oiTicia!who is authorized by law or ordinance to administer the community's flood�lain management ordinance can complete
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s)and sign below.
G1. �_�The information in Section C was taken from other documentation that has been signed and emhossed by a licensed surveyor,
engineer, or architect who is authorized by state or local law to certify elevation inforrnation. (Indicate the source and date of the
elevstion data in the Comments area below.)
G2. �_� A comme±nity official completed Secdon E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or
Zane AO.
G3. �_�The foL'owing in"rormatio;, ptems G4-G9) is provided for community floodplain managemeni purposes.
G4,PERMIT NUMBE4 G5. DATE PERMIT ISSUED G6. DAl"E CER7IFICATE OF COMPLIANCElOCCUPANCY
ISSUED
G7. This permit has been issued for: �_� New Construction �._J Substantial Improvement � �m� Datum:
G8. Elevation of as-built lowest floor (including basement)of the building is: ft. (m) Datum: _
G9. BFE or{in Zone AO) depth of flooding at the building site is: —
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPNONE
SIGNATURE DATE
COMMENTS
_____ �
�
� �Check here if attachments
FEDERAL EMERGENCY MAIVAGEIVIEN I AC�tNt;Y O.M.f3, IV4. 3067-0077
��������� NATIqNAL FLOOD INSURANCE PROGRAM Expires Oecember 31. 20Q5
oP�� ��k'��— ELE14"ATIOIV C��TIF�CATE
3 ,�L "� �- "� �1(�� Im ar�anC: Read the instructians on a es 1 -7.
SECT101V A-PR�P�RTY OWNE12 INFORMATION For Insurance Company Use;
JING OWNER'S NAME PRlicy Numb�r
alm H r
BUIL.DING STREET AD�RESS(tncfudin Apt.,Unit, Suite,an or Bldg.No,)OR P.D.ROUTE AND BOX NO. Gompany NAIC Number
1 8675 T 1 9 Nnrth r.����-`I�
CITY STATE ZtP CODE
('1 c�arwatar Florida ���64
p{�pp[�R Vumher,Legal Description,etc.)
, � 1�aC�
g�p � � �p g �.� sory,etc. Use a Comments area,if necessary.)
�
LATITU � DATUM: SOURCE: �_�GPS(Type):
( �k#°-; �� _�NAD 1983 �_��SGS Quad Map �^�Other
D�P� -
t�� �URAI�GE RATE 1111AP(FIRM)INFORMATIOIV ,
61. NF11 ����a ` c � COUNTY NAME 63.STATE
Cit S �o��� Pinellas �1 '
B4. Mlrt.. � �� d7.FIRM PANEL D6. FLO�� B9.BASE FLOOD ELEVATION(S)
I � _.- �i�r._inc�!C��nnr[- `nnjc/C1 (7nr�.0�n,��sP�earh of tlo�dinal
� _ + ��=c�,T:v ,:.�.l.., n:� I r.�; i - I
� ���t � Sept 3 �003 AF 9
B70. Indi� � � ,�L;� :a or base flood depth entered in B9. "�
(� �L � :termined �_!Other(Describe}:
811. Indic J �w NGVD 1929 ��.� NAVD 1988 �,�Other(Describe):
8�2. Is th � tem(GSRS)area ar Otherwis�Protected Area (OPA)? ���Yes �.�.� IVo
Des,
�tG 1-I�N C-BUIL.pING ELEVATION INFORMATION(SURVEY REQUIRED)
C1. Building elevations are based on: ���Consiruciion Drawings' �_�Building Under Construction" � x�Finished Construction
new Elevation Certificate will be required when construction of the builtiing is complete.
� �ilding Diagram Numher $ (Select the building diagram most similar to the huilding for which this certificate is being completed-see
pages 6 and 7. !f na diagram accurately represents the building,provide a sketch or photograph.)
C3. Elevations-Zones A1-R30,AE, AH,A(with BFE),VE,V1-V30,V(uuith BFE),AR,AR/A,ARIAE,AR/A1-R30, ARlAH, AR/AO
Complete ltems C3.a-i below according to the building diagram specified in Item C2. State the datum us�d. !f the datum is difFerent from
the datum used far the BFE in Section B,convert ttie datu(n to that used for the BFE. Show field measurements and datum conversion
calculation. Use the space provided or the Comments area of Section D or•Sectioh G,as appropriate,ta dacument the datum conversion.
Datum NAVDRA Conversion/Gomments NGVD 29 ( � � AO fPPt" - NAVr�gg�foe�►
Elevaiion reference rnark used Does the elevation reference mark used appear on the FIRPJt? J_�Yes ��� No
� a)Top of bottom floor(including basement or enclosure} 5 .�ft.(m) �
�1 b) Top of next higher floor 9 2 {�.{m) b
��
� c) Bottorr�of lowest horizontal structura!member(V zones only) 1�1�A ._.ft.{m) o o //'
❑ d) Attached garage (top of slab) rj..�,g._._ft.(m) �� 1/�:z� l-i_____
W /� / b
� ej Lowesi el�vation oi mcchinery a,idio;�quiNr�ent �� - /'�� �'., /
servicing the building (D�scribe in a Gomments areaJ 9 .Q ft.(m) :E� " /�(VY�'�_�'t l �'L
O �/�
� � Lowest adjacent(finished)grade(LAG) 5 .�ft.(m) z N . �
Q g) Highest adjacent(finished) grade(HAG) 6 ,S.-ft,(m) � �'� � 7� �' �
❑ h) No.of permanent openings(flood vents)w(thin y ft.above adjacent grade (�_ �;,
❑ i)Total area of al! permanent openings(flood vents)in C3.h q sq. in. (sq. cm)
• SECTIUIV D•SEIRVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION '
'fhis certification is to be signed and sealec�by a land surveyor,engineer,or architect authorized by law to certify elevation infarmation.
I certify that the informatierr in Sc�ctiv�s,A, B,and C on this certificate�epr�sents my best efforts to interpret the data available.
/understand that any faJss statemeni may be punishable by fine or imprisonment under 78 U.S. Code, SecGon 7009.
CERTIFIER'S NAME LICENSE NUMBER LS 4 O 8 6
Michael �7. 'Bzker
TITLE Land Sur�Te�or COMPANYNAME Michael Baker Associates
ESS CITY '� STATE ZIP CODE
220 S. �afford Ave. Tar on S rin Fl - 34
SIGNATURE DATC• � ELEPHONE
�,,,, .:% �. August 1 0, 2004 7-938-5026
� `'�--�.�_ _�. .��_._____.._
�
!(viPO1:TANT: 1n thesa spaces, copy the corr:;sponding iMbr�nation fron�Sectior�A. ror insuran�e�u<<;N���y�:..�.
6lFiLD1NG STREET ADDRESS(Including Apt.,Unit,Suite,andlor Bidg,No.)OR P,O. ROUTE AND BOX NO. Policy Number' '
North
CIIY STAI E ZIP CODE Campany NAIC Number
Cle�rwater Florida 33764
5EC71C)N D-SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICA710N {CONTINUEQ) �
Gopy both sides of this Eievation Ceriificate for(1)community official, (2)insurance agent/company, and (3)bu+lding owner. �
COMMENTS
('�i 1 v�,iOns J'c�f rPnr[�[� tn Pi nal 1 aG C"rnintv Ranrhmark " C3IT1�uS C��
Elevations 7 081 feet NGVD29 converted t-o elevation- H 1t�� fPPt
NAVD 8� ..L�tu !j'� S��rI.QQ� !�/03GG /?.66
C3e Air Condlt1011el'ZfGK C�'�' s�'�"�� �'� ��Qtra�C�� I—I Check here if attachments
SECTION E- BUILDING ELEVATION INFORMATIQN (SURVEY NOT t2EQUiRLD) FOR ZONE AO AND Z(�NE A(VI/ITHOUT BFE)
For Zone AO and Zone A(without BFE), complete ltems E1.through E5. If the Elevation Certificate is intended for use as supporting
information for a LOMA or L�MR-F, Section C must be completed.
E1. Building Diagram Number (Select the buiiding diagram most similar to the building for which this certificate is being completed–
see pages 6 and 7. If no diagram accurately represents the buiiding,provide a sketch or photograph.)
E2. The top af the bottom floor (including basement or enclosure) of the building is �_�_�ft. (m) I—I—I �n. (cm)�_� above or �_� below
(check one)the highest adjacent grade. (Use natural grade, if available.)
E3. For Buiiding Diagrams 6-8 with openings (see page 7),the next higher floor or elevated floor(elevation b) of the building is
I—I—I ft• (m) I-_–I—l�n. (cm) above the highest adjacent grade, Complete Items C3.h and C3.i on front of form.
`4. TMa top of;he plat'o;;:;af m�ch:r.a�;?rdlor e;!ii�ment se�vicing the buildina is �_�_i ft. (m) �.�I_I in. (cm) �_� above or�_� below
(check one)the highest adjacent grade. (Use natural grade, if available.)
E5. For Zone AO only: li no flood depth number is available, is the top of the bottom flaor elevated in accordance with the community`s
floodplain mana�ement ordinance? � � Yes � � No 1 � Unknown The local official must certify this information in Section G.
SECTIQN F-PROPERTY QWNER(LlR pWNER'S REPRESECVTATNE) GERTIFICA710N
The proper[y owner or owner's authorized representative who completes Sections A, B,C (Items C3.h and C3.i only), and E for Zone A
(without a FEMA-issued or community-issued BFE) or Zone AO must sign here. The siatements in Sections A, B, C, and E are correct to
the best nf m knowled e.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIV�'S NAME
ADDRESS CITY STATE ZIP CODE _
SIGNATURE OATE TELEPHONE �
COMMENTS
I_� Check here if attachments
� � � SECTION G• COMMUNITY INFORMATION (OPTIQNAL)
The local o#ficia!who is authorized by law or ordinance to administer the comrnunity's floodplain management ordinance can complete
Sections A, B, C {or E), and G of this Elevation Certificate. Camplete the applicable item(s) and sign below.
G1. �_�The information in Section C was taken from other documentation that has been signed and emhossed by a licensed surveyor,
engineer,or architect whc is authorized by state or local law to certify elevation inforrnation. (Indicate the source and date of the
elevation data in±he Comments area below,)
G2. �_�A comm�.±nity offi�ial completed Sec�on E for a building located in Zone A(without a FEMA-issued or community-issued BFE) or
Zone AO.
G3. �_�The fol;owing iniormatio;� (ltems G4-G9) is provided for community flooclplain managemeni purposes.
G4.PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPUANCE/OCCUPANCY
ISSUED
G7. This permit has been issued for: J_� New Construction �_) Substantial improvement
G8. Elevation of as-built lowest floor (including basement)of the building is: _ft. (m) Datum:
G9. BFE or(in Zone AO) depth of flooding at the building site is: _ft. (m} Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
— �
�_�Check here if attachments
�aC.�$"'°��r����
�� � �� CITY OF CLEARWATER
� �v ,� i. �a �.
�,���� ��W DEVELOPMENT & NEIGHBORHOC�D SERVICES DEPARTMENT
�,t.�'�y�.,_;�. �""a�e�
���"/y�!'��� c�°�� POST OFFICE BOX 474H CLEARWATER FLO�DA 33758-4748
�.I�i/i��Y��r}�i� 7 I
�'I�i���' .��� MUNICIPAL SERVICES BUILDING, ZOO SOUTH MYRTLE AVENUE,CI.EARWATER,FLO�uDn 33756
'�''a"�° TELEPHONE�7Z� 5�2-4567 Fn�c(72� 562-4576
MEMO OF REVIEW FOR CORRECTNESS & COMPLETION
In accordance with participation in the NFIP/CRS program,all elevation certificates are required to be reviewed for correctness and completion prior to
acceptance by the community. This complete form shall be attached to all elevation ceRificates maintained on file and provide with requested copies of
elevation certificates.
The attached elevation certificate requires corrections by the surveyor of section(s) prior to acceptance by the community
The attached elevation certificate is complete and correct
X Minor corrections have been made in the below marked sections by Community O�cial
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1. BUILDING OWNER'S NAME Policy Number
A2.BUILDING STREET ADDRESS(including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number
18675 US HWY 19 N#248
CITY STATE ZIP CODE 33767
A3. PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
A4. BUILDING USE(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)
A5. LATITUDE/LONGITUDE(OPTIONAL): HORIZONTAL DATUM: SOURCE:�GPS(Type):
(##°-##'-##.##" or ##.�°) ❑ NAD 1927 ❑ NAD 1983 ❑ USGS Quad Map�Other
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
1.NFIP COMMUNITY NAME&COMMUNITY NUMBER B2.COUNTY NAME 63.STATE
64.MAP AND PANEL g5.SUFFIX B6.FIRM INDEX DATE B��FIRM PANEL gg.FLOOD ZONE(S) B9•BASE FLOOD ELEVATION(S)
NUMBER EFFECTIVE/REVISED DATE (Zone AO,use depth of flooding)
12103C0128
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 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
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. Building Diagram Number 5 (Select the building diagram most similar to the building for which this certificate is being completed-see pages 6 and 7. If no
diagram accurately represents the building,provide a sketch or photograph.)
C3. Elevations—Zones A1-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,ARlA,AR/AE,AR/A1-A30,AR/AH,AR/AO.
Complete items C3.-a-i below according to the building diagram specified in Item C2.State the datum used. If the datum is different from the datum used for the
BFE in Section B,convert the datum to that used for the BFE.Show field measurements and datum conversion calculation. Use the space provided or the Comments
area of Section D or Section G,as appropriate,to document the datum conversion.
Datum Conversion/Comments
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? ❑Yes ❑No
e) Lowest elevation of machinery or equipment servicing the building(Describe in Comments area) ft.(m)
h) No.of permanent openings(flood vents)1ft,above adjencent grade
i) Total area of all permanent openings(flood vents)in C3.h sq.in.(sq.cm)
Comments:
Date of Review: Community Official:
�elevation certificates shall be maintained by the community and copies with the attached memo made availab/e by request
Ftz.at�K H�sRnw>,MAYOR
GEORGE N.CRE7'EKOS,COUNCILMEMBGR JOIIN DORAN,COUNCILMEMftER
PAUL F.GIASON,COUNCILMEMBER � CARI.EN A.PE7'ERSEN,COUNCILMEMBER
��EQUAL EMPLOYMENI'AND AFFIRMATIVE AC170N EMPLOYER��
, _ _ _ _ - ___ _ _ ___
� � ' ELEVATION CERT'iFICA�E O.M.B.No3067-0077
ExprresMay.�l, 1993
. FEDERAL EMERGENCY MANAG�MENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTIO'd: iJse o�this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to
•provide elevation information necessary to ensure compliance with applicable community floodplain management ordinances,to
�etermine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Fievision(LOMA or LOMR).
Instructlons for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION _ FOR INSURANCE COMPANY USE
.S� BUILDING OWNER'S NAME POLICY NUMBER
P'
i
0 STREET ADDRESS(Including Apt.,Unit,Suite and/or Bldg.Number)OR P.O.ROUTE AND BOX NUMBER COMPANY NAIC NUMBER
M �
�?" OTHER DESCRIPTION(Lot and Block Numbors,etc.)
► $c��Z 5 N � v•s- � 9 � 9 c.o �� i�t �
CITY STATE 21P CODE
�i.EA2�ArE�t �1-aR�o,4 34(�2�
SECTION B FLOOD INSURANCE RATE MAP(FIRM)INFORMATInN
Provide the following from the proper FIRM (See Instructions):
7.COMMUNITY NUMBER 2.PANEL NUMBER 3.SUFFIX 4.DATE OF FIRM INDEX 5.FIRM ZONE 6.BASE FLOOD ELEVATION
(in AO Zones,use depth)
0 oi -I - 199i - t .00
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:' ! I I i !,I �feet NGVD(or other FIRM�atum—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
of � � �.!�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 af��J.0 feet NGVD(or other FiRM dat�m—see Section E3, Item 7).
(c). FIRM Zone A(without BFE). The floor used as the reference level from the selected diagram is U.U 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 �.�;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 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: If the e/evation datum used in measuring the e/evations is different than that used on
the F1RM (see Section B, Item 7J, then convert the elevations to the datum system used on the F/RM and show ihe conversion
equation under Commenfs on Page 2.)
4. Elevation reference mark used appears on FIRM: ❑ Yes ❑No (See Instructions on Page 4)
5.The reference Ievel elevation is based on: ❑ actual construction ❑ construction drawings
.. . (NOTE: Use of construction drawings is on/y valid if ihe building does not yet have the reference/eve/floor in p/ace, in which
case this certificate will only be valid for the building during the course of construction. A post-construction Elevation Certificate
will be required once construction is comp/ete.)
6.The elevation of the lowest grade immediately adjacent to the building is:�J.�! feet NGVD(or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
•+ If the community official responsible for verifying building elevations specifies that the reference level indicated in Section C, Item 1
is nct the"lowest floor"as defined in the community's floodplain management ordinance,the elevation of the building's"lowest
floor"as defined by the ordinance is: ' � ! � .�� 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�MAY 90 REPLACES ALL PREVIJUS EDITIONS SEE REVERSE SIDE 1=0R CONTiNUATION
, _ _ _ _
' � S�GTION E CERTIFICATIOM
• ` _
This certification is to be signe�by a land surveyor,engineer,or architect who is authorized by staie or locai law to cen�fy elevation
information when the elevation information for Zones Ai—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 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 unabl�to certify to breakawaylnon-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.
I certify thai the information in Sections B and C on this certificate represenfs my best efforis to interpret the data avai/able.
1 understand that any false statemeni may be punishable by fine or imprisonment undei 18 U.S. Code, Section 1001.
CERTIFIER'S NAME UCENSE NUMBER(or Affix Seaq
��,va� �. ��cr's #37�f7
TI�'LE COM�ANY NAME
�t2ESIllENr �RNr_RSTZJIJE t.N611J�-�QINr__� .SU2�6yfNfi ,J�(c.
ADDRESS CITY STATE Z�p
3 � . �� s �. e���� � �Q,�- 3y� �5
SIGNAT E DATE PHONE
t-2. 4� P�13- �i�ll-�7(0?
Copies should be made of thi ertificate for:1)c�mmunity official,2)insurance agent/company,and 3)building owner.
COMMENTS:
•
�
ON �H ON PILES, I
g�pg BASEMENT PIERS,OR COLUMNS
i
A V A A V
20NES ZONES ZONES ZONES ZONES
REFERENCE
REFERENCE g�E LEVEI REFERENCE
LEVEL �ppp LEVEL
ELEVATION
n`4�:
ti'iqf;:,,.i::-:`.:;:;. F.4....�t s,2'`
-.).:. �tik`.f?;:�r:ra�:#`y';,.
:yi�:.
:�:�::i'r::::/:;'`. :: jg;• BASE
BASE ... ApJACENT��:'�:���rf: REFERENCE FIOOD
FLOOD �'.. �..�.. ..::t�i::
�- ELEVATION REFEFENCE ADJACENT GMDE :pr� LEVEL ELEVATION
' LEVEL GRADE �
'i}y+�1S:. ;Z`,':
�f'�.i:��ik:�t:4�,�y:
:.:_�..�:.'::.j�:�:'��:.: 'w'
••••• ���:.
:.�l.:
�,�1 �`�'i�DJACENT?.
:.:,r,:,� �.���::,:.:.._::�:;;::.:.:::�;:�.: �'�:: GRADE �.
..:...��':�.�.':;�:::�.'::�.:�::':�::'�:�;��:11f 11:'�:'': .
The diagrams above illustrate the points at which the efevations 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