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755 ISLAND WAYU.S. DEPARTMENT OF HOMELAND SECURITY ELEVATI4N CERTI FICATE FEDERAL EMERCiENCY MANA(iEMENT AGENCY NationalFloodlnsuranceProgram Important; Read the instructions on pages 1-9. � SECTION A- PROPERTY INFORMATION A1. @uilding Owner's Name �� l�' 1 M n�� L�� ` �" Il� A2. Building Street Address (including Apt., Unit, uite, and/or Bldg. No.) or P.O. Route and Box No. %�"J � IS l� A 1�.1 !a Y✓�4 City � L �-!� � �� .. � state � z�F code 3 7,%(0 �s, Tax Parcel Number, Legal Descriptlon, etc.) - Odo - OZ'7rp OMB No. 1660-0008 Expiration Date: July 31, 2015 A4. 6uilding Use (e.g., Residential, Non-Residentlal, Addition, Accesso etc.) �E�'� 1�� f � �-- A5. Latitude/Longitude: Lat. 2� � 5g �� • �P �� Long. B�-° �� I Z� 7" Horizontal Datum: ❑ NAD 1927 ACl 1983 A6. Attach at least 2 photographs of the bufiding if the Certiflcate fs being used to obtain flood insurance. A7. Building alagram Number �: E�J `�, A8. For a building with a crawlspace or enclosure(s): � A9. For a building wfth an attached garage: `�z � a) Square footage of crawlspace or enclosure(s) � sq ft a) Square footage of attached garage � sq ft b) Number of permanent flood openings ln the crawispace b) Number of permanent flood openings in th�ched garage or enclosure(s) within 1.D foot above adjacent grade within t.0 foot above adJacent grade c) Total net area of flood openings in A8.b aq In c) Total net area of flood openings in A9.b sq In d) Engineered flood openings7 ❑ Yes ❑ No d) Enginee�ed flood openings? ❑ Yes ❑ No SECTION B- FLOOD IN8URANCE RATE MAP (FIRM) INFORMATION B1. NFIP Community Name 8 Community Number 82. County Name �� G �.1=A�K �/�T �-FZ ) 25 �� B4. Map/Panel Number 65. Suifix B6. FIRM Index Date B7. FIRM Panel B8. Flood � 2 � � � � � I � � �. g_ � � _�� Effective/Revised Date Zone s) 9-b�-o� �� B3. State � 89. Base Fiood Elevation(s) (Zone A0, use b se flood depth) . �� 810. Indicate the source of the Ba e Flood Elevation (BFE) data or base flood depth entered in Item B9. ❑ FIS Profile FIRM ❑ Community Determined ❑ OthedSource: B11. Indicate elevatlon datum used for BFE in Item B9: ❑ NGVD 1929 �AVD 1988 ❑ Other/Source: ,,_,I iB12. Is the buiiding located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑ Yes Ly'No Designation Date: ❑ CBRS ❑ OPA SECTION C- BUILDINC3 ELEVATION INFORMATION (SURVEY REQUIRED) C1, Building elevations are based on: ❑ Constructlon Drawinge* ❑ Building Under Construction' [�Finished Constructfon 'A new Elevation Certificate wlll 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, ARIA, AR/AE, AR/A1-A30, AR/AH, AR/A0. Complete Items C2.a-h below according to the building dia ram specifled In Item A7. In Puerto Rico only, enter meters. � Benchmark Utfiized: � D ��-� Z• �' 3� r? Vertical Detum: 7� 2% � �� v p �'�� Indicate elevation datum sed fo� the elevatlons in items a) through h),below. �7 NGVD 1929 ❑ NAVD 1988 �'OthedSource: Datum used for building etevations must be the same as that used tor the BFE. Clteck the measurement used. a) Top of bottom floor (includf�g besement, crawlspace, or enclosure iloor) ii� .� � reet ❑ meters b) Top of the next higher floor �2.�% � [�eet ❑ meters c) Bottom of the lowest ho�fzontal structural member (V 2ones oniy) � ❑ feet 0 meters d) Attached garags (top of slab) �1,.�_ C9'�et ❑ meters e) Lowest elevation of machinery or equipment servicing the building ' _.1Q,.� ❑ feet ❑ meters (D scr(be t e of e ui ment and location In Comments) � � '` fi� -��S i. � � e Yp q p ,.,.,� � � Lowest adjacent (tinished) g�ade next to building (LAG) Z- Ll�teet ❑ meters k , g) Highest adjacent (flnished) grade next to building (HAG) � L,.g.,'.t�et ❑ meters �-� h) Lowest adJacent grede at lowest elevation of deck or stairs, including structural suppo�t �,� I�reet ❑ meters � SECTION Q- SURVEYOR, EN�INEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation . �,�,,, ,�£„ �, � v,� information. 1 certily thaf fhe fnformatlon on fhis CertiBcafe represenfs my besf e/fo►fs to interpret fhe dafa avallable. �.�>+ .�•-,;� �., I�u.n/derstand fhaf any false statement may be punishable by fine or Impr/sonmenf under 18 U.S. Code, Secflon 1009. Q`� � 4 , j��4 �� L1�' Check here if comments are provided on back of form. Were latftude and longitude in 5ection A provided by a :r r'°�' �,.,�!�' �n "'e�r5�, � L�7'� Check here if attachments. Iicensed land surveyor? [�}''�es ❑ No '"+ ��,�,�� .� R, � Certifier's Name LARRY L. EVANS Title LAND SURVEYOR Address 1460 BELTREES Signature Company Name STE.9 City DUNEDIN, � Date 2_ Z,� _ � 7) License Number PLS # 2937 EVANS LAND SURVEYING, INC. State FL ZIP Code 34698 Telephone (727) 7343821 ..1 , . „ ' • � � �' � �;�, �� , °� i ;} i � # � @?'�± h "�t�V}' °tic� �'�,�; • :� . �r = �L.tVA 1 IUN l:tK 111-I[:A 1 t, p8q@ 'L IMPORTANT: In these spaces, copy the corresponding information from Section A. Buildin� Street Address (including Ap,t., Unit, Suite, and/or Bidg. No.) or P.O. Route and Box No. � �74v l I., fG N�Imbe� I City �� .,�� State �� ZIP Code �brri��itl� fJA i SEGTION D— SURVEYOR, ENOINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner. Gomments � Z , �l ; � / �..j('j'�� 1'� 1 O .k ��G GC�J✓� �,�.'_E,�<j�� bh-1 �I� �,f� � L/.S� I �o�'NI' / 5ignature Date E -(B�JILDIN(3 ELEVATION INFORMATION (SURVEY NOT o a - �,� -� �.� FOR ZONE AO AND ZONE A(WITHOU�' BFE) For Zones AO and A(without BFE), complete Items E1—E5. If the Certiflcate is intended to support a LOMA or LOMR-F request, complete Sectlons A, B, and C. For Items E1—E4, use natural grade, if availabie. Check the measurement used. In Puerto Rico only, enter meters. E1, Provide elevation fnformation 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 (fncluding basement, crawlspace, or enciosure) is ❑ feet ❑ meters C) above or [] below the HAG. b) Top of bottom floor (inciuding basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the LAG. E2. For Buiiding 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 fioor (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 HAO. 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 avallable, is the top of the bottom floor elevated In accordence with the community's floodptain management ordinance? ❑ Ye� ❑ No ❑ Unknown. The local officiai must certify this information in Section G. SECTION F— PROPERTY OWNER (OR OWNER'S REPRE3ENTATIVE) CERTIFICATION The property owner or owner's authorized representative who compietes Sections A, B, 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, 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 i SECTION O— COMMUNITY INFORMATION (OPTIONAL) " � The local offlcial who is authorized by law or ordinance to administer the community's floodplaln management ordinance can complete Sections A, B, C(or E), and G ;of this Elevation Certiflcate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8—G10. In Puerto Rico only, enter meters. ! G1. ❑ The information in Sectfon 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 informatlo�. (Indicate the source and date of the elevation data in the Comments area below.) ', G2. ❑ A community offlcial completed Section E for a buiiding located in Zone A(without a FEMA-issued or community-issued BFE) or Zone AO. i G3. ❑ The following information (Items O4—G10) is provided for community floodpiain management purposes. i G4. Permit Number G5. Date Permit Issued G6. Date Certif(cate Of Compliance/Occupancy Issued G7. This permit has been issued for: � New Constructfon ❑ Substantlal Improvement G8. Elevation of as-6uilt lowest floor (including basement) of the building: ❑ feet ❑ meters Datum G9. BFE or ((n Zone AO) depth of flooding at the building site: ❑ feet O meters Datum G10. Community's design flood elevation: ❑ feet ❑ meters Datum Local Official's Name Cammunity Name Signature Comments Title Telephone Date Check here if attachments. . , . , ELEVATION CERTIFICATE, page 3 guilding Photographs See Instructions for Item A6. IMPORTANT: In these spaces, copy the corresponding information from Section A. FoR INSURANCE COMPANY USE Building Street Address (including Apt., Unit, uite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number: > S �' � City State ZIP Code �� Company NAIC Number. GLE��Z �, - If using the Elevation Certificate to obtain NFIP flood insurance, affix at least 2 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." When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page. . ��I��\��t i I�ir �� ■■ _ �� / �� L�" t . '�� i`� ��r�Y.�.�.��. �_ . IY P! u'.:3 �.i �, � � �� _ � ■ = ,�. ■ . �d�l �°�~. . . . , .... yY ....1. �.... .„ A , ".. �..... � ��1� ..:...� �,� . '�� '��W��I �.� I � � ..__. !�._.�..�r— ��'k?�°K,m�VT n t;.'r;sa. ,'�.. .; J �r .�� 4 a i�,«Y � � r� � � 5Y ,.t..��. .. .:. . " 'm.-.. ..`�"r� 4`n��\� �,.: �':�s... \/�u� � �� . , � , ,... ,; ._�: .. � Y� - .� � � � � � � � � � � 0 � � V • \� � \