1055 CHARLES STl) S: DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008
� F�deral Emergency Management Agency Expires March 31, 2012
National Flood Insurance Program Important: Read the instructions on pages 1-9.
SECTION A - PROPERTY INFORMATION
A1. Building Owner's Name J.S. PERRY & COMPANY
A2. Building Street Address (including Apt., Unit, Suite, and/or Bidg. No.) or P.O. Route and Box No.
1055 CHARLES STREET
City CLEARWATER State FL ZIP Code 33755
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
PEALE PARK, LOT 14 W 1/2 LOT 15, BLOCK B, P.B. 12, PG. 17
A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) RESIDENTIAL
A5. Latitude/Longitude: Lat. N-27-59-37 Long. W-82-47-33 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 crawlspace or enclosure(s): A9. For a building with an attached garage:
a) Square footage of crawlspace or enclosure(s) 0 sq ft a) Square footage of attached garage 308 sq ft
b) No. of permanent flood openings in the crawlspace or b) No. of permanent flood openings in the attached garage
enclosure(s) within 1.0 foot above adjacent grade 0 within 1.0 foot above adjacent grade 0
c) Total net area of flood openings in A8.b 0 sq in c) Total net area of flood openings in A9.b 0 sq in
d) Engineered flood openings? ❑ Yes � No d) Engineered flood openings? ❑ Yes � No
SECTION B- FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
61. NFIP Community Name & Community Number 62. County
CITY OF CLEARWATER 125096 PINELLAS
FLORIDA
B4. Map/Panel Number 65. Suffix B6. FIRM Index B7. FIRM Panel 68. Flood 69. Base Flood Elevation(s) (�
12103C0106 H Date Effective/Revised Date Zone(s) AO, use base flood depth)
8/18/2009 5/17/2005 AE 11'
610. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9.
❑ FIS Profile � FIRM ❑ Community Determined ❑ Other (Describe)
611. Indicate elevation datum used for BFE in Item 69: ❑ NGVD 1929 � NAVD 1988 ❑ Other (Describe)
612. 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' ❑ Buiiding 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 building diagram specified in Item A7. Use the same datum as the BFE.
Benchmark Utilized PIN CO DISK AURAL F Vertical Datum ELEV=22.41 NAVD1988
Conversion/Comments
Check the measurement used.
a) Top of bottom floor (including basement, crawlspace, or enclosure floor) 10.2 � feet ❑ meters (Puerto Rico only)
b) Top of the next higher floor 10.4 � 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) , 9.5 � feet ❑ meters (Puerto Rico only)
e) Lowest elevation of machinery or equipment servicing the building 9.8 � feet ❑ meters (Puerto Rico only)
(Describe type of equipment and location in Comments)
� Lowest adjacent (finished) grade next to building (LAG) 9.4 � feet
❑ meters (Puerto Rico only)
g) Highest adjacent (finished) grade next to building (HAG) 10.1 � feet ❑ meters (Puerto Rico only)
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 authorized by law to certify elevation
information. I certi(y that the information on this Certificate represents my best efforts to interpret the data available. �,,,,,,,,.,,,
I understand that any false statement may be punishable by fine or imprisonment under 18 U. S. Code, Section 1001.
. � � ••,,
� Check here if comments are erovided on hark nf fnrm Were latitude and longitude in Section A provided by a � ° y ' �
licensed land surveyor? ❑ Yes � No
Certifier's Name LAUREN PENNY, P.S.M. License Number #4931
Title LAND SURVEY'OR Company Name L.R. PENNY AND ASSOCIATES, INC.
Address 10730 102 AVENUE NORTH City SEMINOLE State FL ZIP Code 33778
Signature �� �_� Date 7/19/2013 Telephone 727-398-4360
FEMA Form 81-31, Mar 09
See reverse side for continuation.
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Replaces all�preVious editions
IMPORTANT: In these spaces, copy the corresp
Building Street Address (including Apt., Unit, Suite, and/or
1055 CHARLES STREET
City CLEARWATER State FL ZIP Code 33755
ing information from Section A.
. No.) or P.O. Route and Box No.
SECTION D- SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenVcompany, and (3) building owner.
Comments LOWEST EQUIPMENT IS AN AIR CONDITIONER.
Signature
yitu i S
❑ Check here if attachments
SECTION E- BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE), complete Items E1-E5. If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A, B,
and C. For Items E1-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters.
E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent
grade (HAG) and the lowest adjacent grade (LAG).
a) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or � below the HAG.
b) Top of bottom floor (including basement, crawlspace, or enclosure) is . ❑ feet ❑ meters ❑ above or ❑ below the LAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions), the next higher floor
(elevation C2.b in the diagrams) of the building is ❑ feet ❑ meters ❑ above or ❑ below the HAG.
E3. Attached garage (top of slab) is ❑ feet ❑ meters ❑ above or ❑ below the HAG.
E4. Top of platform of machinery and/or equipment servicing the building is ❑ feet ❑ meters ❑ above or � below the HAG.
E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management
ordinance7 ❑ Yes ❑ No ❑ Unknown. The local official must certify 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, and E for Zone A(without a FEMA-issued or community-issued BFE)
or Zone AO must sign here. The stafements in Sections A, 8, and E are correct to the best of my knowledge.
Property Owner's or Owner's Authorized Representative's Name
Address
Signature
Comments
City
Date
State ZIP Code
Telephone
❑ Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C(or E),
and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8 and G9.
G1. ❑ The information 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 certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.)
G2. ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE) or Zone AO.
G3. ❑ The following information (Items G4-G9) is provided for community floodplain management purposes.
G4. Permit Number
G7. This permit has been issued for:
G5. Date Permit Issued
❑ New Construction
G6. Date Certificate Of Compliance/Occupancy Issued
❑ Substantial Improvement
G8. Elevation of as-built lowest floor (including basement) of the building: ❑ feet ❑ meters (PR) Datum
G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters (PR) Datum
G10. Community's design flood elevation ❑ feet ❑ meters (PR) Datum
Local Official's Name
Community Name
Signature
Cominents
FEMA Form 81-31, Mar 09
Title
Telephone
Date
_❑ Check here if attachments
Replaces all previous editions
�
�:
Building Photographs
See Instructions for item A6.
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
1055 CHARLES STREET
Clty CLEARWATER State FL ZIP COd@ 33755
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 on the
reverse.
SEE ATTACHED SHEET OF PHOTOGRAPHS
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