867 ISLAND WAYU.S. DFPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Proqram
ELEUATION CERTIFICATE
ant: Read the instructions on paqes 1-9
SECTION A - PROPERTY INFORMATION
luding Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box
867 ISLAND WAY
LOT 44, ISLAND ESTA7'ES OF CLEARWATER, UNIT 8, PB. 64, PGS. 73 & 74,�PINELLAS COUNTY TAX # 05-29-15-434
A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) RESIDENTIAL
A5. Latitude/Longitude: Lat. 27D. 58' 57" N. Long. 82 D. 48' 48" W Horizontai Datum: ❑ NAD 1927 X NAD 1
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 g�
a) Square footage of crawlspace or enclosure(s) WA sq ft a) Square footage of attached g;
b) No. of permanent flood openings in the crawlspace or b) No. of permanent flood openii
enclosure(s) within 1.0 foot above adjacent grade N/A
adjacent grade
c) Total net area of flood openings in AS.b N/A sq in c) Total net area of flood openin�
d) Engineered flood openings? ❑ Yes ❑ NO
d) Engineered flood openings?
SECTION B- FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
CITY OF CLEARWATER # 125096
72103C0102
PINELLAS COUNTY
G Date I Effective/Revised Date I Zone(s)
08-18-09 09-03-03 qE
o � u. �naicate tne source or tne t�ase Flood Elevation (BFE) data or base flood de th entered in Item B9.
❑ FIS Profile X FIRM ❑ Community Determined �] Other (Describe)
B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 X NAVD 1988 ❑ Other (Describe)
812. Is the buiiding located in a Coastal Barrier Resources System CBRS) area or Otherwise Protected Area (OPA)?�
Designation Date �] CBRS ❑ OPA �
SECTION C- BUILDING ELEVATION INFORMATION (SURVEY RE�UIR
C1. Building elevations are based on: ❑ Construction Drawings� ❑ Building Under Construction` X
'A new Elevation Certificate wili 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, AFi/A, AR/AE, AFVA1-A3�, AR/AH, AI
below according to the building diagram specified in Item A7. Use the same datum as the BFE.
Benchmark Utilized CLEARWATER I Vertical Datum NGVD 1929
Conversion/Comments NONE
a) Top of bottom fioor (including basement, crawispace, or enclosure floor)
b) Top of the next higher floor
c) Bottom of the lowest horizontal structural member (V Zones only)
d) Attached garage (top of slab)
e) Lowest elevation of machinery or equipment servicing the building
(Describe type of equipment and location in Comments)
f) Lowest adjacent (finished) grade next to building (LAG)
g) Highest adjacent (finished) grade next to building (HAG)
h) Lowest adjacent grade at lowest elevation of deck or stairs, including
structural support
9.2
wa
WA
8.8
8.7
8.5
8.7-
N/A
Check the measurement us
X feet ❑ meters
❑feet ❑ meters
❑feet ❑ meters
X feet ❑ meters
X feet ❑ meters
X feet ❑ meters
X feet ❑ meters
❑feet Q meters
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 certify that the information on this Certificate represents my best efforfs to interpret the data available.l
understand that any faise statement may be punishable by fine or imprisonment under 18 U.S. Code, Secfion f001.
❑ Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a
licensed land surveyor? X Yes ❑ No
DAVID K. PREVOT
PROFESSIONAL SURVOR AND MAPPER
6154-A SPRINGER DRIVE
�.,.�
� ��V��, �v��n o i-o i, iviar uy
LS # 4934
� Name BAY LAND SURVEYING
City PORT RICHEY State FLORIDA ZIP Code 34668
See reverse side for continuati�n
OMB No. 1660-0008
Expires July 31, 2015
iii�wance �.ofTlpaftY US@:
pany
age:
age 506 sq ft
�s in the attached garage
within 1.0 foot above
> in A9.b N/A sq in
❑ Yes X No
.ORIDA
3ase Flood Elevation(s) (ZonE
10, use base flood depth)
12.0
❑ Yes X No
shed Construction
Complete Items C2.a-h
uerto Rico only)
uerto Rico only)
uerto Rico only)
uerto Rico only)
uerto Rico only)
Rico only)
Rico oniy)
Rico only)
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City
SECTION D- SURVEYOR, ENGINE�R, OR ARCHITECT CERTIFICA
IMPORTANT: In these spaces, copy the corresponding information from Section A.
�ildmg Street Address (includ�ng Apt., Unit, Suite, and/or Bldq. No.) or P.O. Route and Box No_
424 MIDWAY ISLAND
State FLORIDA ZIP Code 33767
SECTION D- SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CO
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenbcompany, and (3) building owner.
ON E- BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO
For Zones AO and A(without BFE), complete Items E1-E5. if the Certificate is intended to support a LOMA or LOMR-F reque
and C. For Items E1-E4, use natural grade, if availabie. Check the measurement used. In Puerto Rico only, enter meters.
E1. Provide elevation information tor the following and check the appropriate boxes to show whether the elevation is above c
(HAG) and the lowest adjacent grade (LAG).
a) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ abo�
b) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ abo�
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pa es 8-9 of Instri
(elevation C2.b in the diagrams) of the buiiding is . ❑ feet ❑ meters ❑ above or [� below the HA
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 o
E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the comm
ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G.
SECTION F- PROPERTY OWNER (OR OWNER'S REPRESENTA
The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A(without a
Zone AO must sign here. The statements in Sections A, 8, and E are correct to the best of my knowledge.
Propertv Owner s or Owner s Authorized Reoresentative's NamP
SECTION G - COMMUNITY INFORMATION
I he local otticial who is authorized by law or ordinance to administer the commurnty's fioodplain management ordinance can
and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items
G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed ;
is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Com
G2. ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-i�
G3. ❑ The following information (Items G4-G9) is provided for community floodplain management purposes.
G7. This perrnit has been issued for: ❑ New Construction ❑ 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 fiood elevation ❑ feet ❑ meters (PR) Datum
�e Company Use:
ED)
Check here if attachm
D ZONE A (WITHOUT BF
complete Sections A, B,
below the highest adjacent gr
� or Q below the HAG.
� or ❑ below the LAG.
tions), the next higher floor
below the HAG.
s floodplain management
TION
or community-issued BFE)
iete �eccions H, tt, c; (or t)
d G9.
or, engineer, or architect wt
� area below.)
BFE) or Zone AO.
Check here if attachmE
uilding �'hoto�rap�s
_ Continuation Page. 14-445IEC
867 ISLAli�D VVf1�' For insurance company use:
Buildina Street address (includina A t., Unit, Suite) or PO Box Polic Number
City CLEARWAI'ER STATE I'LORIDA Zi 33767 Com any NAIC Number
If subinitting more photographs than will �t on the proceeding page, affix the additionat photoaraphs below. Identify all photographs
with: date taken:"front vie�d' and "rear view" and if required ," right side" and `9eft side view". '
DATE TAKEN 06-17-2014
FRONT VIEW RIGHT ViF.W
REAR VIEW
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