61 ACACIA ST�
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U.Ss DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
Nac;onal Flood insurance Program IMPORTANT: Follow the instructions on pages 1-9.
SECTION A - PROPERTY INFORMATION
A1. Building Owner's Name
LROY PEARL
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
CiTy CLEARWATER
FL
c�
OMB No. 1660-0008
Expiration Date: July 31, 2015
FOR INSURANCE COMPANY USE
Poik,y Number.
ZIP Code 33767
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
PARCEL 05-29-15-54666-027-0020, BLOCK 27, LOT 2, MANDALAY SUB, PLAT BOOK 014, PAGE 032, PINELLAS COUNTY, FLORIDA
A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) RESIDENTIAL
A5. Latitude/longitude: Lat. 27-9895 Long. �2-a249 Horizontai Datum: ❑ NAD 1927 �x 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 EIGHT
A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage:
a) Square footage of crawlspace or enclasure(s) ��� sq ft a) Square footage of attached garage NA sq ft
b) No. of permanent flood openings in the crawlspace or b) Number of permanent flood openings in the attached garage
enclosure(s) within 1.0 foot above adjacent grade 6 within 1.0 foot above adjacent grade NA
c) Totai net area of flood openings in A8.b 136 sq in c) Total net area of flood openings in A9.b N�A sq in
d) Engineered flood openings? ❑ Yes � No d) Engineered flood openings? ❑ Yes � No
SECTION B- FLOOD INSURANCE RATE MAP (FlRM) INFORMATION
B1. NFlP Communt�y Name & Commun�� yNumber B2. County Name
CLEARWATER CITY OF 125096 PINELLAS
B4. Map/Panel Number B5. Suffix B6. FlRM index Date B7. FlRM Panel Effective/ B8. Flood Zone(s)
Revised Date
12103CU102 (�, 08/18I2009 09f03l2003 AE
610. indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item 69:
❑ FlS Profile � FlRM ❑ Commurtity Determined � Other/Source:
� B3. State FL
B9. Base Flood Elevation(s) (Zone
A0, use base flood depth)
� i.o �
811. Indicate elevation datum used for BFE in Item 69: ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source:
812. Is the buiiding located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑ Yes � No
Designation Date: J / ❑ CBRS � OPA
SECTION C- BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction* � Finished Construction
*A rtew Elevation Certificate will be required when construction of the buiiding is comptete.
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/A0. Complete Items
C2.a-h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.
8enchmark Utilized: GPS Verticat Datum: �VD 1988
Indicate elevation datum used for the elevations in items a) through h) below. ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source:
Datum used for building elevations must be the same as that used for the BFE.
a) Top of bottom floor (inc{uding basement, crawispace, or enclosure fioor)
b) Top of the next higher floor
c) Bottom of the lowest horizontal structural member (V Zones oniy)
d} Attacfied garage (top of s{ab}
e) Lowest elevation of machinery or equipment servicing the building
(Describe type of equipment and location in Comments)
f� towest adjacerrt jfinished) grade next to buiiding (LAG)
g) Highest adjacent (finished) grade next to building (HAG)
h) Lowest adjacent grade at lowest elevation of deck or stairs, including
structura! support
Check the measurement used.
4.00 � feet ❑ meters
6.16 � feet ❑ meters
N/A � feet ❑ meters
��A � feet ❑ meters
s.o1 � feet ❑ meters
3-81 � feet � meters
4.10 � feet ❑ meters
3�81 � feet ❑ meters
SECTION D- SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION
This r.ertifir.atinn is tn he si�ned and cealed hv a land survevnr_ enoineer_ nr arrhitecT mrthnri�Prl hv law tn rortifv clavatinn
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EI,EVATION CERTIFICATE, page 2
IMPORTANT: In these spaces, cop�r tl�e carrespondin� a�Famation Trom Section A.
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
61 ACACtA STREET
City
CLEARWATER
State ZiP Code
FL 33767
FOR INSURANCE COMPANY USE
Policy Nu�r:
Comparry NAIC Number:
SECTION D— SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community officiai, (2) insurance agent/company, and (3) building owner.
Comments
Signature
Date 09/17/2013
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 L�MR-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 enciosure) 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 buiiding is N� . A � 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
ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G.
SECTION F— PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFlCATION
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 statements in Sections A, B, and E are correct to the best of my knowledge.
Property Owner or Owner's Authorized Representative's Name
Address
Signature
Comments
City
Date
State ZIP Code
Telephone
❑ Check here if attachments.
SECTION C — COMMWNITY INFARMATiON (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—G10. In PueKO Rico only, enter meters.
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 A0.
G3. ❑ The following information (Items G4—G9) is provided for community floodplain management purposes.
G4. Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued
G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement
G8. Elevation of as-buitt towest floor (including basementf of the building: . ❑ feet ❑ meters Datum
G9. BFE or (in Zone AO) depth of flooding at the building site: . ❑ feet ❑ meters Datum
G10. Community's design flood elevation: . ❑ feet ❑ meters Datum
Local Official's Name
Community Name
Signature
Comments
Titie
CLEARWATER CITY OF Telephone
Date
❑ Check here if attachments.
FEMA Form 086-433 (7/12) Replaces all previous editions.
ELEVATION CERTIFfCATE BUILDING PHOTOGRAPHS
CONTINUATION PAGE
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
ADDRESS:
61 ACACIA ST
CLEARWATER, FL 33767
PICS TAKEN 9/14/2013
FRONT VIEW AND CONTINUING AROUND BUILDING
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Sinkhole Inspection Form. SDII 8060640
9/18/2013 9/25/2013 FRJM6829269 - 01 Renewal �] New Business �
Date Ass�grred Date Inspected
RISk ID
PEARL.ROY
APP��canUNamed Insured
67 ACACIA ST
Property Address
CLEARWATER, FL 337671404
City, State, Zip
PINELtAS
County
502.419.7883
AppBcanUlnsured Phone Numbsr
S011 C�obai CorpotaGon
Ffrm
Billy jones
�nspector Name
SAMUEI. JACKS
Agent Name
954.583.5444
Agent Phone Number
Aitemate Representapve (For Inspec6on Scheduling Purposesy
Aftemate AppliqnVlnsured Phone Number Altemate Representative Pho�e ►Vumber If
5096/5096 { APP�able)
Is the Narned Insured physically present for the inspection? �tes ❑ No
If yes, ask the Named insured the foliowing questions:
Has the house or property at the address to be insured for sinkhole loss ever
experienced damage or loss from sinkhole activity, or experienced cracking, shifting or � Yes to
bulging of a foundation, wail or roof?
2. Is any insured under this policy aware of any sinkhole, sinkhole activity, sinkhole
investigation, ground study or inspection for sinkhole activity or for any cracking, � Yes
shifting or buiging of a foundation, wa11 or roof of the house or property to be insured
under the policy?
3. Has any insured under this policy ever requested a sinkhole investigation, submitted a
claim for a sinkhole loss, or made a claim for loss or damage from cracking, shifting or � Yes
bulging ofa foundations, wall or rooFaf the house or property to be insured under this
policy?
`, 5tg' rrSfur - X
ed Insured or Authorize__- d R r— � ---
epresentative Signature of Inspector - "'
Citizens Sinkhole Inspection Form ver. 3
Ed. 7/2/2012 1 � P a � e
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Instructions: Answer Yes � No f or N/A for each Ruestion_ Por any "Yes" answer, provide detaiis as indicated
below (use additionai pages as needed):
• f n addiuon to front / rear elevation photas and general photos of home, provide photos (close ��p and penpective phobo) of items
marked "yes".
• For all cracks:
o Provide width and length measurements.
o [f patched and re-cracked ask owner: how often patched, how many times patched, how long before cracking reeurs, ete.
o if 1/8 inch or larger, ask when filst Octurred or noted by owner. Have any changes occurred and over what time kame.
o Facterior cracks, indicate if cracks penetrate wail or are cosmetic.
o If home painted over cracks and re-cracldng has occurred, are tfie cracls paint Hlled or not, when was home paineed,
how long before ccacks reappeared, etc.
• Garage cracks: Qn floor or walls, pmvide measurements for width and length. Photos should illusttate if localized or if radiates and
eactends ta walls.
• Depressions/erosion - indicate if credible reason for depression/erosion visible.
• Any actions taken by the insnred [or prior owner) to repair any damage visible? Describe.
Exterior•
1. Any depression in yard?
2. Any sinkholes or depressions
in yard on adjacent properties?
3. Any soil erosion around
foundation?
4. Cracks in foundation?
5. Cracks in exterior wall?
Interior•
1. Interior doors out of pl
uneven, stickin�, eic.
2. Doors/windows out of
3. Compression cracks/breaks
4. Floors out of level or sloped?
5. Attached cabinets puiled
away from watl?
6. Cracks on interior walis?
7. Cracks on interior ceiling?
8. Cracks on Aooring or floor
tile?
1. Wall-to-stab cracks?
2. filoor cracks radiate to wall?
Y/N
.J
N
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Y/N
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Detaiis per above
above
Y/N Detaiis er above instructions:
1�+
Note: For all Appurtenant Structures, Sidewalks, Driveways, Pools, Pool Decks, Patios, etc.:
Y�N Details er above instructions:
1. Cracks noted?
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2. Uplift noted?
r
3. Cracks or damage in poot
itself? �
4. Cracks In pool deck or patio? �
Cttizens Sinkhole Inspection Form ver. 3 Ed. 7/2/2012
2j-
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Additional [nforma�ton•
Pruvide an overview of the general condition of property. Inctude descriptions of any hazardous or advene conditivns
�.v�:r,: �t an �rnperry (e.g. empty paois, unfenced �ools, trampolines, skateboard/birycle ramps, vicious jexotic animals kept
on the p��ei�iises, any other eJCisting damage, tc) +
St no� �� s• 1o�lL �F''r1. �� .�-i.-.�e��l l`�f_. �.3 .-i-t� Q.� 0. S-� ��7 S�" �� r�
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If a townhouse of row house, provide a descripiion of the outside condition of continuous/adjacent huiidings and
surrouading areas (within 1/a milej. Also, nrovide a photo of adioinin� structures_
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Provide the distance to the nearest known sinkhole activi
�1-'Zes; Kn oti.�n Coni--�.+,a� .5,., i��� � O�e-+, ,, .-�c� �� c�.l .�-�. �,J 1.C� M ��-
identify and provide a description of any other relevant information or findings discovered during the inspectioa
� �
If unable to schedule, please provide the dates, times and numbers for each attempted contact If the inspection was refused,
please provide a detailed explanation.
Examples of e.�cpected commentary:
+ Depressions in yard appear to be caused by.....
• Holes in yard filled several times by owner over past year....
• Cracks in struciure first apgear (approximate time fcame)...
• Patching was completed and recracldng appeared within (time frame)....
• Garage floor cracking radiates to exterior walis....
� Soii erosion or wash out present appears ta be caused by....
Citizens Sinkhole Inspection Form ver. 3 gd, ��2�2p12 3(
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Sinkhnle Scnening Inspeclion
YParf Karidenee — Ciearwa[er, FloriAa
Clnim No_ FRIMhX292h9
SAII Projocr No_ 8060fut�
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Claim No. FRJiYi6829269
SDII ProJCCt Nu. 8060690
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Sinkhole .Scrnening Inspeclian
Ycarl Residencc - Clearwater, Florida
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Pear/ Residence — Clearwater, Florida
Claim Nn. FRIM6�429269
SUI/ 1'mjecE Nn. 811h(I(r10
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Claim No. FRIM68292h9
JUIL Project No. 8060640
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Pearl Residence — Clearwater, F[ori[Ia
C(aim No. /�lU,ti168292h4
SDlI Project A'o. 806116411
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