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901 DEMPSEY STU.S. DE�ARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008 FEDF.RAL EMERGENCY MANAGEMENT AGENCY Nntional Flood Insu�cePmgrvm IMPORTANT: Follow the instructions on pages 1-9. Expiration DBte: July 31, 2015 SECTION A - PROPERTY INFORMATION A1. Building Owner's Name JOHN J STIVEY A2. Building Street Address {including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. FOR INSURANCE COMPANY USE Policy Number. Comparry NAIC _-- �ty CLEARWATER State � ZIP Code ����5 A3. Property Description (lot and Block Numbers, Tax Parcei Number, Legal Llescription, etc.) PARCEL 21-29-15-47466-006-0160, BLOCK 6, LOTS 16&17 & SW'LY 15FT LOT 15, LAKE BELLEYIEW, PLAT BQpIC 0p9, PAGE 141, PINELLAS COUNTY, FLORIDA A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) RESIDENTIAL A5. Latitude/Longitude: l.at z7•9499 Long. 82.7943 Horizontal 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. Buiiding Diagram Number EIGHT A8. For a building with a crawispace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(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 openin2s j� the attachssi gar�ge_ _ enc-Tosure s w�Ffi�n3:0 "foo�-a� e a �3'acenf grade within 1.0 foot above adjacent grade NA c) Total net area of flood openings in A8.b 2� sq in c) Total net area of flood openings in A9.b wA sq in d) Engineered flood openings? ❑ Yes � No d) Engineered flood openings? ❑ Yes � No SECTION B- FLOOD INSURANCE RATE MAP (FlRM) INFORMATION B1. NFlP CommunClFN4RWA ER�CITY O� N25�09�6r 62. County Name P�NE�� 63. State � B4. Map/Panei Number B5. Suffix 86. FlRM Index Date 87. FlRM Panei Effective/ 68. Flood Zone(s) B9. Base Flood Elevation(s) (Zone ' Revised Date A0, use base flood depth) 12103C0108 H �/18l2(109 OS/172005 AE q3.0 � B10. Indicate the source of the Bage Rood Elevation (BFE) data or base flood depth entered in ttem B9: ❑ FlS Profile � FlRM ❑ Community Determined ❑ Other/Source: 611.Indicate eievation datum used for BFE in Item 69: ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source: 612.Is the building located jn a Coasial Barrier Resources System (CBRS) area or Othervvise Protected Area (OPA)? ❑ Yes � No Designation Date: / / ❑ CBRS ❑ OPA� SECTION C- BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction* � Finished Construction 'A new Elevation Certificate will be required when consVUCtio� of the building is complete. C2. Elevations - Zones A1-A30, AE, AH, A(with BFE), VE, Vi-V30, Y(with BFE), AR, AR/A, AR/AE, AR/Al-A30, AR/AH, AR/AO. Compiete ttems C2.a-h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters. Benchmark Utilized: GPS Verticai Datum: NAVD 1988 Indicate elevation datum used for the elevations in items a) through h) below. ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source: Datum used for buildine elevaUOns must be the same as thar ��sad tnr tne R� a) Top of bottom floor (including basement, crawispace, or enciosure floor) b) Top of the next higher floor ' c) Bottom of the lowest horizontal structurai member (V Zones only) d) Attached garage (top of slab) e) Lowest elevation of machinery or equipment servicing the buildi�g (Describe type of equipment and location in Comments) � Lowest adjacent (finished) grade next to building (LAGj g) Highest adjacent (finished) grade ne� to building (HAG) h) Lowest adjacent grade at lowest elevation of deck or stairs, including structural support Check the measurement used. 37.5 � feet ❑ mete�s `��� � feet ❑ meters WA � f�t ❑ meters N/A � feet ❑ meters 37.83 � feet ❑ meters 37.5 � feet ❑ meters 37_92 � feet ❑ meters 37�� � feet ❑ meters SECTION D- SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION This certification is to 6e signed and sealed by a land surveyor, en�ineer, or architect authorized bv law to certifv elevation EL�VA'�ION CERTIFlCATE, page 2 IEVIPORTANT: In these spaces, copy the co►respondi�g informatioo from Section A. `Building Street Address (including Apt., U�it, Suite, and/or Bldg. No.) or P.O. Route and Box No. 901 DEMPSEY STREET ��tY State ZIP Code CLEARWATER FL 33756-3405 FOR INSURANCE COMPANY USE Policy Number: Company NAIC Number: SECTION D— SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/comparry, and (3) buiiding owner. Comments IF EQUIPMEM' IS IISTEO ON PRIOR PAGE IS BASE OF AIR CONDITIONER UNIT THIS CERTIFICATE IS NOT TO BE USED FOR CONSTRUCTION OR DESIGN, IS FOR FIOOD INSURANCE USE ONLY Signature Date o2/04/2015 SECTION E- BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE) __ __--� � � �FE3: cemp�ete items-�1—E�. �f�he 6eri+fieateis inter+ded 4e-snppart-aif�MA�r-LOMf2-F reqnest; eomplete Seetiens-A; B�nd E. _ 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 foilowing 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, crawispace, 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 Cr9 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� . p' 0 feet ❑ meters � above or ❑ below the HAG. E3. Attached garage (top of slab) is . � feet ❑ meters � above or ❑ below the HAG. E4. Top of platfortri 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 lmttom floor elevated in accordance with the community's floodplain management ordinance? � Yes ❑ No ❑ Unknown. The local officiai must certify this informatio� in Section G. SECTION F— PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFlCATION The property owner or owner's authorized represerr[ative who completes Sections A, B, and E for Zone A(without a FEM�4issued or community-issued BFE) or Zone AO must sign here. The statements in Sections A, B, and E are correct to the besi 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 G — COMMUNITY INFORMATION (OPTIONAL) The locai 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 Puerto 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 iaw to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. ❑ A community official compieted Section E for a buiiding located in Zone A(without a FEMA-issued or community-issued BFE) or Zone A0. G3. ❑ The fotiowing 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-built lowest floor (including basement) 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 FEMA Fortn 086-433 (7/12) fttle CLEARWATER CITY OF Telephone Date ❑ Check here if attachments. Replaces all previous editions.