654 HARBOR ISLANDU.3, DEpARTMENT OR HOMELAND 9ECURITY
FEDERA6 EMEROENGY MANAOEMENTAOENCY
NulionalF7ood Insurdnae Progra�rr
A2.
��n �-� � IJ hi
ELE�,/ATION CERTIFI�ATE
Important: Read the instructions on pages 1-�8.
3ECTION A = PROPERTY INFORMATION
! �; �JC� I �t S
Unit, Su( e, andJor Bldg. No.) or p.0
���
and eox No.
OMB No. 1660-0008
Expiration Date: July 31, 2015 �
A4. Buliding Use (e.g., Realdentlal, Non-Resldential, Additlon, Accesaory eta.) �� � C� � NT/ L,
A5. Latltude/Longitude: Lat. 2- '° S� � " g L�.� � 5g ��j ,
T ��__� _l___._ � Lon i�72-° Horizontal Datum: p NAD 1827 NAD �1883 �
: A6. Attach at least 2 photograpfls o( the bu(Iding If the Certlflcate le bein g used t o o b t a i n fl o o d i n e u r a n c e:
; A7. Bufiding Dlagram Number �
• A8. F'or a building wlth a crawiaPace or enclosure(s); �
' a) Square footage of crewl�pace or encloaure(s) �i� A9. For a building with an aHaohed 8arage: .�� �
b) Nurriber ot permanent ���� openings In the crewiepace ap ft a) Square footage of atteohed ga[age 8y ft
or enclosure(s) withfn 1 6`�tidC above adJacent gratle b) Number of permanent flood'openinga In.the attached Daraga
withln 1.O.foot above adj�cent grade
c) Total net erea of flood o�� �i9gs in AB.b _,�,
�- �9 �n c) Totel net aree of flood openinga In A�.b �, aq In
d) Engl�eered flood openings7 ❑ Yes ❑ No d) Engineered t1ood openings2 [7 yes �, No
$ECTION B— FLOOp IN3URANGE RAT� MAR (FIRM) INFURMATION
81. NFIP Communiry Name & C�Rmmunity Number 62. County Name .
��F�� W,��('�K.. f IN�I.I..��'j e3.stete �Lt�l�Ip,6,
- 84. Map/Panel Number B5. Sufflx B6. FIRM Index Date B7. FIf2M Panel
80. Flood 89: 6ase Fiood Elevation(s) (Zone
�Z � D��, Q�(a � � Effective/Revised Date Zone a
Q�— I(�'j — Og o �) . AO; use 11�f�ood depthj
�:- �-�3
� 810. Indicate the source qfthe Base Fiood Elevation (9FE) data or baee flood depth entered In Item 88.
❑ FIS Profile �IRM ❑ Commuhity Determined � Other/Source: .
811. Indloate elevatfon datum used for BFE In Item B9: p NOVD 1929 t;v� NAVI] 1988
C7 OthedSource:
B12. la the build(ng located In a Coastel Barrler Resources System (CBRS) area or Otherwise Protected Area (OPA)7
Deslgnatlon Date: ❑ CE1RS . Cj OPA
SECTION C — BUILD
EL�VA�'IQN INFORMATI�N (SURVEY REQUIRED
f� Yes L�' No
C1. Building elevatlons are based on: C] Conetructlon Drawihsa" Q Building Under Constructlon' tJ Finiahed Constructlon
"A new Elevation Certlflcate will be requtred when conattuctlon of the huilding is oompiete.
C2. Elevations —�onea A1-A30, AE, AH, A(with 6FE), VE, Vt—V30, V(with BFE), AR, AR/A, Aft/AE, AR/A1—A30, AR/AH, AR/AO. Compiete Items C2.a—h
below according to khe bufld n dlagram speclfied in Item A7. In Puertb Rfco only, enter mete .
Benchmark Utilized: G�'r� � �LV�/ � -�O� vert�cal Datum: � 5• Z 52�
Indicate elevetion datuni uaed For th� elevationa In items a) throu8h hJ belpw. ❑ NOVD 1829 AVD 1988 �7 Qther/Source:
Datum used for bulldfng elevatiqn$ muat be the same a� that uged fot'the BFE.
Check the measurement used:
a) Top of bottotn floor (including basement, crawispece, or enclosure floor) �� feet ❑ meters
bj Top of the next hlgher floor t ❑(e�t � C� meters
c) Bottom of the lowest horizontal structural member (V Zones oniy) NLa � feet � meters
� d) Attached aarage (top oCalab) �. � . [�et (] meters
e) Lvwest elevation of inechinery or equipment a�rvicing the building _�, 2 feet [] metera
(Deacrlbe type of �quipm�nt and locatlon in Comments)
� Lowest adjacent (ffnishedj grade next to bufiding (LAG) �,� '[�j'feet p meters
g) Mgliest ad)acent (flnished) grade next to buliding (HAG) _�,,�_ [a'�eet C] metecs ,
h) Lowest adJacent grade at lowest elevaUon o( deck or ataira, tncluding structutal aupport ►��P� [] (eet ❑ meters
SECTION D- SURVEYOR, ENOIN�ER, OR ARCHIT�CT CERTIFICATION
This certi(ication is to be signed and sealed by a lend surveyor, engineer, or architect authorized by iaw to certlty elevation `
informatfon. I cenlfy that lhe Informaf/on on this CeNlf7cafe re resents m best efiorfs fo lnte "����� '
F? y ry�ret the dafa avallable. ��,, ,�� _ .,��
�I un erstand that any fslse stafemenf may be punlshable by flne orlmprlsonment under 18 U.S. Code, Secllon 1001. �,3a'� ,�'
Check here if commenta are provided on beck of form. Were Iatitude and Ion8ltude tn S tlon A provided by a- ��'� " `+��+: � �
_/� ,� u• �.�.,,�� ;�� ',�. �~_
I]� Check here If attachments. Iicensed land surveyor9 [r]' Yes ❑ No T; ��,, �. w�+ �
v„�" ��a� �„ �.
Certifier's Naine LARRY L. EVANS License Number PlS # 2937 . ; i p�'� �`��� .: � ti
Title LAND SURVEYOR Company Name EVANS LAND SURVEYINO, INC. �� �'^ hs��¢"; ��� ��''
,, ���,t�.. '�"'.�1 �.
� ° � � 3+� "� �°
Addresa 1460 BELTRE 5T STE. 9 City DUNEDIN, State FL ZIP Code 34698 �,�µ" ;���a"' � a,
� � � ��; , ., : �_ �°
Sfgnature � , �u Date I I _ ��_ � � Telephone (727) 7343821 '�✓�,��, "' °a• > 't.,^��, "' '
TM'T Me t�L•.v
A I IVN 4ktt 11PICA 1�, page e
)RTANt: In tNese spac�s, copy the corresponding Informatlan fronn Section A.
ng S,treet A ress (lhclud g Apt, Unit Sui e, and/or Bldg. No.) or P.O. Route and Box No.
� �d.. i�� �.�o � r��.�. ►J r� _
r 1
Cify Gf �n p 1,�' State ZIP Code � �i ��1 '��� � � ' �
I.� 1"� h++ V� �T ��,., � '�.a � ��7 � ; i' , i.i� [�i��}�,[��s "��va� s�..,. �tr.,;l��.a�
SEC710N D- BURVEYOR, ENC�3INE�Ft, OR AREHITECT CEFiTIFICATION (GONTINU�Dj
Copy bQth sides of this.�leva0on Certl[icate for (1) Community oiflcial, (2) Insurence epent/company, and (3) building owner.'
� Comments C 2� 2.� i �: /�1�..1 �,��T'�-12. I O(Z. %��C.� f�l� �(Z�.`J5o 12- b1.J �-jZ4�UN1� (���/�L P�-
' Signeture �,, Date � � ,,.Z� _ Z,p � (�,.
�
; BECTION E— ILpINO �LEVATION INFORMATI4N (SURVEY NOT REqUIR�D) FOR Z(7N� AO AND ZONE A(WITHOU BF�) .
5 . . . . . . . . . , . . •
For Zonea AO and A(without BFE); complete Itema E1—�6. If ths Certlficate la Intended to aupport a LOMA or LbMR-F requesf, complete Sectlans A, B,
and C. For Items E1—�4, use natu�af grAde, if availeble: Check the measurement used. in Puerto Rico only, enter meters:
` E1. Provid� elevation Information for the following and check the appropriate boxee to ahow whether the elevatlon Is above o� below the higheat ad)acent
grade (HAO) and the lowest ad)a�enf grade (LAO).
a) 7op of bottom itoor (Including basement, arawlapace, nr encloeure) is Cj feet ❑ metera [I above or [1 balow.the HAQ.
b) Top of bottom iloor (Including basement, crawlspace, or enaloaure) is . � feet ❑ meters CI above or L7 below the LAG.
[2. For Building Diagrama 6--8 witfi permanent flood openinga provided In 9ectlon A Reme 8 and/or 9(se�e pagee 8-9 of Instructions), the next higher fioor
(elevation C2.b i� the dlegrems) ot the building Is ❑ Feet ❑ metera ❑ above or ❑ below the HAG.
E3. Attached garage (top of slab) is � feet ❑ meters ❑ above or ❑ beiow the HAO.
E4. Top of pietform of machinery end/or equipment aervicing the building (s ❑ feet ❑ metere ❑ abave or �] below, the HAQ,
E5. Zone AO oniy: If no flood depth number Is aveilable, is the top of the bottom floor elevated In accordanoe with lhe community's tloodplain management '
ordinance? C� Yes ❑ No ❑ Unknown. The local official must certify this informatfo� (n Ssotlnn Q.
� SECTION F- pROp�RTY OWNER (OR OWN�R'8. REPRESENTATIVE) CERTIFIGATION
..�
The propetiy owner or owner's autliorized representAtive who oompletes Sectlona A, B, end E for Zone A(without a FEMA-isaued or.community-lesued BFE)
or Zone AO must ai�n here, The statements In Sectiona A, B, end E are correct to the beet oF my knowladge.
Property Owner's or Owner's Authorized Representative's Name
Addrese City State ZIP Code
Slgnature i bate 7elephone
Comments
SE�TION O — COM
[� �heok hera i( attachments.
ItY INF(]RMdTION (�PTIONAU
rhe loCal offlolal Who Is authoriZed by law or orqinence to aamm�ater aie ovnnnNrn�y,e ��v�u��a��� ���a��QaQ���o,�.....+ ........... ...... .._...�.___ ____._._ -. , . ..
q,f thla Elevatlon Certificate. Compiet� the applicebla Item(s) and eign below. Check the meaaurement used In Items Gd=�10. in Puerto Rlco only, enter meters.
G1. ❑ The intormation In Section C wes teken ftorri other documentatlon lhat has been signed and aealed bya Itcensed aurveyor, enginee�; or architect who
la authorized by law fo certify elevatlon informatlon. Qndicate the source and date of th� elevation data in the Comments area below.)
C32. ❑ A communfEy offlcfal cvmpleted 5ectlon E for a bullding located in Zone A(without a FEMA-Isaued or community-issued BFE) or Zone AO.
Ca3, ❑ The iollowing in(ormaflon Qtema GA—o10) Ia provided for community floodplain management purpoaes:
G4. Fermit Number G5. Date Permit Isaued G8. Date CerQficate O( ComptlancelOccupancy Isaued
U7. This permlt has bsen Issued for. ❑ New Construct�on ❑ Subetantiai Improvement
G8. Elevatlon of as-bulit lowest floo� Qnciuding basement) oi the buildingc . [] feet ❑ meters Datum
;;9. BFE or Qn Zone AO) depth of flooding at the building alte: Cl feet G� metera Datum
a10. Communiry's design flaod elevations ❑ feet � metere Datum
LoCai Ofticlal's Nas�ie
Community Name
Title
Telephone
Date
Slgnature
Comments
� Chaek I�re if attachments.
r . s
ELEVATIQN CERTIFICATE, page 3 Building Photographs
See Instructions for Item A6.
IMPORTANT: In these spaces, copy the corresponding information from Section A. FC1R IN�URANC� CQMPANY US�;
Building Street Address includin Apt. Unit, Suite, and/or Bidg. No.) or P.O. Route and Box No. Policy Number; �
�� � ' � �
_ ' . , 1�- ti
City 5tate . ZIP Code Coinpany NAIC Numlier. �
C�L - fZ V�r � � �
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 fiood openings or vents, as
indicated in Section A8. if submitting more photographs than wili fit on this page, use the Continuation Page.
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