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U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE oMB No. �sso-000e
Federal Emergency Management Agency Expi�es MarCh 31, 2012
NationWl Floo�Insurance Program Important: Read the instructions on pages 1-9.
SECTION A-PROPERTY IN�ORMATION `+� 1"`1 �YI1����G�� ��'�l 1���4i� ��� r+
A1 Building Owner'S Name� L� 'r4�f2..,� C• Ctt�I�Y�l�-��. �..-� l�B�' � '�s 3��qy�� UHtij��,��{���;(��,�,������a�x�€¢���������'`° �4v
T � F` "7 {" � �1 PK m �}`
A2. i�ing Strgit�dres�ncluding Apt.,Unit,Suite and or Bldg.No.)or P.O.Route and Box No. p(��(j���p�y�N�� w�������F����,s}�� �ki,
I Inl D R a ��� �.I D � �� 4 �„ �q� � n
n�Y���,at'�f��i�1�S+t�,.��Cx"�i4,�x F�1.;��fi�l�'i,�fit�� ����;'.
c�►y���/a;l�..W�'T���� State �,L ziP code 3.37�7
A3. Pro erly escriphon(Lot and B ock Numbers,Tax P�rcel Number,Legal Description, tc.)
���f' �O. �r�IT � 1�L/�r�D �S-T�4�"'�S �...GI�E W�T�fZ,
A4. Building Use(e.g.,Residential�Non-ReSident�i,Addltiq�,Accessory etc.) R ES�I�EN /Al..
A5. Latitu�e/longitude:Lat. 2-- "r�' B �-�•2-�� Long. ° � 3 . °� Horizontai Datum: []NAD;1927 NAD 1983
A6. Altach at least 2 photograph ot Ihe:building If the�Certificate is being used fo obtain flood insurance. �y
A7. Building Diagram Number� . '' ''
A8. For a buildfng with a crawispace or enclosure(s): A9. For a huiiding with an attached garago:
a) Squere footage of crawispace or enclosure(s) � sq R a) �quare footage of aflached garage � sq ft
b) No.of permanent flood openings in the crewlspace or b) No.of permanent flood openings in the attach garage
enclosure(s)within 1.0 foot above adJacent grade Within 1.0 foot above adjacent g�ade
c) Total net area ot flood openings in AB.b sq in c) 7otal net area of flood openings in A9.b sq in
d) Engineered tlood openings? [�Yes �No d) Engineered flood openings? []Yes [] No
' SECTION B-FLOOD INSURANC�RqtE MAW(FIRM)INFO�tMA710N
B1.NFIP Community Name&Commu ity Number 82.County Name 83.State
�.L,�.i�c �T�k IZSb`,� fo �I N E,L.L�.� �L�
64.MaplPanel Number B5. uffix B6.FIRM Index B7.FIRM Panel B8.Flood 69.Base Flood Elevation(s)(Zone
�2���C � � O(� �-�- Date o EffectfvelRevised Oate Zone(s) AO,use base flood depth)
�-�g- 9 5 -� -05 i4�E.. 1.1�
610. Indicate the source of the Base Flood Elevation(BF�)data or base flood depih entered in Item 89.
❑FIS Profile ❑FIRM Communiry Determined []Other(Describe)
611. Indicate elevation datum used for 6FE in Item B9: ❑ NGVD 1929 ❑NAVD 1988 ❑Olher(Describe)
812. Is the building Iocated in a Coastal Barrier Resources 5ystem(CBRS)area or Otherwise Protected Area(OPA)? []Yes �] No
Designation bate �CBRS �OPA
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� SECTION C-SUILDING ELEVATION INFORMATION(SURVEY RE�lUIRED)
C1, �uilding elevations are based on: ❑Cpnstruction Drawings* ❑ Building Under Constructlon" [� Inished Constniction
"A new Elevation Certiflcate wlll be required when construction of ihe bullding is complete.
i C2. Elevations-Zones A1=A30,AE,AH,A(with BFE),VE,V1-V30,V(wfth BFE),AR,AR/A,ARIAE,AR/A1-A30,ARlAW,AR/AO. Complete Items C2.a-h
below according Eo the.buildinT iagr�specffied(n Item A7. Use the same datum as lhe BFE. 3 �C�� � ���� ��� �
� Benchmark Utilized G I Ty 0 L L W R, G` D�,'� 5 Vertical Datum � ��
� Conversion/Commenls G I�Y f?U(�l.(S �-}�p �L�..�/JS,�'r'I l'�/�..1 �
Check the measurement used.
a) Top of bottom floor(including basement,crawispace,or enclosuCe tloor)��,��f et �meters(Puerto Rico only)
b) Top of the next higher floor fl�, feet I-1 meters(Puerto Rico only)
c) Bottom of the lowest horizontal structural member(V Zones only) ��/� `I]fe t u meters(Puerto Rico only)
� `' d) Attached garage(top of slab) � _,�).�,�eet ❑meters(Puerto Rico only)
' e) Lowest elevation of machlnery or equipment servicing the building _____�,�[�aet []meters(Puerlo Rico only)
(Qescribe type of equipmeni and locatfon in Comments)
t� Lowest adJacent(finished)grade next lo building(L.AG) r,�Q�eet �]meters(Puerto Rico only)
g) Hlghest adjacent(flnished)grade next to building(HAG) �.���'feet []meters(Puerlo Rico only)
h) Lowest adjacent grade at lowest elevation of deck or stairs,including �„�.�[]feet �meters(Puerto Rico only)
structur2l su ort
� SECTION D-SURVEYOR, EN�'�INEER,OR ARCNITECT GERTIFICATION � , .
This cerlification is to be signed and sealed by a land surveyor,engineer�or architect authorized by law to certity elevation °` �
information. I certify that the information on this Certificate rep�sents rriy best efforts fo interpret the data available. ,.,Yy � �' v;��r! �'
I understand that any false statement may be punishab/e by llne or impri�sonment under 18 U.S. Code,SecNon 1001. �;�,��,. ""�"��..��s
c � -
�hecic here if comments are provided on back of form. Were latitude and longitude in,S,�ction A provided by a �,�,o ;" ,��, �a r, '�
licensed land surveyor? [�Yes ❑No ,� ��t`"� �._ � �'`��-, '.
Certifier's Name License Number y *'� '�'�`'���. �'4 'd: '
Larry L. Evans PLS�� 2937 -�j b, 4 a ��
Title � Company Name ��, ; ��,, Y i:, �'` C �'
Land Surve yor Evan4 i,and Snr�.e�ing, Tn�. ., , ,�. r��3�a;�-
Address City State ZIP Code , 4�,+ , ' ��` C ,
14 ' 4 '
Signature �'�+' Date elephone € �!-� �' ,, "� �
' , �,,,w�� p _�,/,�-��„ (727) 734-3821 � k
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FEMA Form 81 1, M 09 5ee reverse side for continuation. Fteplaces all previous editions
� .
IMPORTANT: In these spaces,copy the corresponding infortnation from Sectinn A. ` ��"P ���� ""' "' �'�'��`U� r�'+��k,��;
Building StPeet Address(ineluding Apt.,Unit,Sui e,and/or Bldg.No.)or P.O.Route and Box No. ��+�i��A �fi ��� ,' ��$�����k��,��a`
�31 W I nl D w/�I� P �s l�y tJ D �4
Ciry �. �1�. �+4��Y��4� �,+r!
�..��.�R.��s'T�� (2, Stete �� ZIP Gode s���ili�l¢Hji'F,IA,� �!� ��P^�i� �`!�,'r,�%��'
i � 33]'(� ���k,,�!���������� ;: { �.�t ��'����'�a,x,��
3�CTION D-3URVEYOR, ENGINEER,OR ARCHITECT C�RTIFIGATION(CpN71NUEp)
. . . I ��in �i�����1� �
Copy both sides of this Elevatlon Certiticate for(1)community oHicial,(2)insurAnce agenUcompeny,and(3)building owner. �
Comments G 2�e. � I 5 �/�.l �X.'T�.2 I p R � c. (',O Pl�.�,-S S o 12 0� I S l=.I> �- J�,/t/t�
Signature Date ��
� _._ _.._�_. D¢-Zl�-I 2
L�7 Check here if attechments
S�CTION E-B DING EL�VATION INFORMATION(.SURVEY N01"REqUIFt�D)FOR�QN�A0 ANp ZON�.A�WITHQUT`��E)
For Zones AO and A(without BFE),complete Items E1-E5. IF the Certificete Is Intended to suppprt a LOMA or LOMF2-F reque8t,complete Sectfons A,B,
end C. For Items E1-E4,use natural grade,if av8flable. Check the measurement used. In t'uerto Rico only,enter meters.
E1. Provide elevation information for the following end check ihe appropriate boxes to show whether the elevatian is above or below the highe8t adJacent
grade(HAG)and the Iowest adjacent grade(LAG).
a)Top of bottom iloor(including basement,crawlspace,or enclosure)is � ❑feet ❑meters ❑above or ❑below the HAG.
b)Top of bottom floor(including basement,crawlspace,or enclosure)fs _ Qteet ❑meters ❑�bove or []below the IAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided In Secti�Items 8�dlor 9(see�ages S-9 of Instructions),the next higher floor
(elevation C2.b in the dfagrams)of the buliding is ___�_[�feet mel�rs above or U below the HAG.
E3. Attached garage(top of slab)is []fset[J meters Q above or [� below the MAG.
E4. Top of platform of machinery and/or equipment servicing the building is �,,,�feet ❑mete�s []above or []below the HAG,
E5. Zone AO only: If no flood deplh number is available,is the top of the bottom iloor elevated in accordance wllh the community's floodplain management
ordinance? [] Yes ❑ No 0 Unknown. The local oHicial must certify this information In 5�clion 0.
SEC710N F-PRQP�RTY QWNER(OR OWN�R'S R�PR�SEN?ATIVE)CERTIFIGAtION
The property owner or owner's authorized representative who completea Sections A,B,and E for Zone A(without e FEMA-issued or community-issued BFE)
or Zone AO must sign here. TTie statements in Sections A, B,and E are correct to fhe best of my knowledge.
Property bwner's or Owner's Authorized Representetive's Name
Address Clty 5tate 21P Code
' Signature bale 7elephone
' Comments
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' SECTION(�-COMMW�JITY INFORMATION(OPTIdNAL)
t The local official who is authorized by law or ordinance to administer thb communify's floodplain management ordinance ean complete Sectfpns A,B,C(or ),
` and G of this Elevation Certificale. Complete the appiicable item(s)and sfgn below. CheCk the measurement used in Items G8 and G9.
G1. � The informetion In 5ection C was taken from other documantatlon that has been signed and sealed by a licensed surveyor,engineer,or archltect who
is authorized by law to ceriify elevation information. (ind(cete ihe source and date of the elevation data in the Comments area below.)
i
i' G2. ❑ A community oNcial completed Section E for a building located in Zone A(wilhout a FEMA-issued or community-issued BFE)or Zone AO.
i G3. ❑ The following information(Items G4-G9)la provided for community iloodplain management purposes.
i
i G4.Permit Number G5. Date Permit Issued G8. Date Certiifcate Of CompliancefOccupancy Issued
G7. This permft has been issued for: ❑ New Constructlon �]5ubstanqal Improvement
G8, Elevation of as-built lowesi floor(induding basemenq of lhe bwilding,_ . ❑feet ❑meters(PR} Datum .
( ) p g . []feet ❑meters(PR) Datum
� G9. BFE or in Zone AO dQ th of floodin at the building site
G10.Community'S design flood elevatlon ❑feet ❑mefers(PR) D�tum
Local O�cial's Name ' Title
Community Name Tetephone
Slgnature fJate
Comments
_._. ❑ i
FEMA Form 81-31, Mar 09 Replaces aliprevious editlons
, �uilding �'hoto�raph� '
See Ins ruc i
t k ons for Item A6.
;����or Insur�nce�Co�p���y Use; ?
Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box Na �'�Ii�y Number � �,
�3 � o �� � ;� � r� � �fl � -�� �� �
City State ZIP Code � om��ny�NAl�Nirnber �
� G�-��k(�v�/�-fE�'�.. � • ��
If using the Elevation Certificate to obtain NFIP flood irisurance affix at least two bu'Idin
, i hoto ra hs below accordi
n to
. 9P 9 p 9
the instructions for Item A6. Identify all photographs ' : date taken; "Frvnt View" and "Rear View,"�• �►�#.�equired, "Right
Side View "Left Side View." If submit ' re photographs than will fit on this page, use the Continuatidt��age bn the
reverse. � �.,�
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PLANNiNG & DEVEL.�PMENT DEPARTMENT
` 100 S.MYRTLE AVENUE,2ND FLOOR
CLEARWATER,FL 33756
' • PHONE 727,562�567;FAX:727-562-4865
DECLARATION OF UNITY OF TITLE
rro�rcy oa►„e�: SA L Y�T�� � ����;�lF_ �ig��
r���.aa�: ��3'� Gt/�r�/.�o �s[��
KNOW OF ALL MEN BY THESE PRESENTS, that p�usuant t+� the ordivances of the City of Clearwater
Pertaining to the issuance of building permits and tegula�mg land�evelo�t activities,the undersigned,being
the fee ownea(s)of the following d�cnbed real property(insert below or at�ch legal dcscrip�ion)situated 'm the
City of Clearwater,County of Pinellas and Sta�e of Florida,to wi�
do hereby make the following declaration of o�ditions,limitatians aad restrictions on said lands,her�er tn be
lmown and t+efen+ed to as a DECLARATION OF Il1JITY OF TITLE,as to the fnllowing p�rticulais:
1. That the aforesaid plo#or combination of separate lots, Plot� Pazce1s,acresge or portions thereo� sha11
hereaf�er be reganded as and is hereby declared to be unified undef one titte as an indivisible building site.
2. That the said prop�ty shall henceforth be c�onsidec�ed as o�e plat or parcel of land, and that no portion
thereaf s�ll be sold, assigned,tr�nsferred, conveyed ar devised separa�lY except in its entiretY, as one
plot or paroel of land.
3. That this Dsclaration of Unity of Title shall constitut�a cove�nt to nm with t�e land,as provided by law,
and shall be binding upon the undersigned,and ti�e heirs, s��ss�s and assigac of the undersigned, and
all parties claiming vnde,r t�em until such time as the same may be released in writing under the order of
--- the City Manager of the City of Cl�. The undersigned also agc�e(s)t}�t this instrument sliall be
recorded in the public reooids of Pinellas County,Florida.
Signed, sealed,wi�d and acianowledged this j�" �j+of ,Q,`>r�� ,202 Z at
Clearwata,Florida.
OWNF
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STATE OF FLORiDA
COUNTY OF PWELLAS �e �y�,ffi�yr����� S�'�' �j,of
_�� ,ZOl�bY�._i,.•d.rt�'C l��s4:.w �kb �
behatf of wham the io�meat was acoc.vted.
YATINHAI,a11SiRA
''�' iYK I�/Y�SSldll#ff 1OY413 � Notaty Public Signature
� ��M►42Di5
�"�rw.�-L,i..i S -�U�. Name ofNotary Printod
" Notmy commissi�xmnba:_(JG 1@GI�i�
(SEAL A�VE� ��y� �
pmduoed idwtisc�ion�_
1`9pe of i�ifi�on Produoefl_ f� (��-
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