1058 ELDORADO AVE� U.S.' ENTOFHOMELANDSECURITY E�,.EVATION CERTIFICATE
FE . MERGENCY MANAGEMENT AGENCY OMB NO. 16GO-00O8
war��. ood Irrs'urance Program Important: Read the instructions on pages '!--9. Expiration Date: Juy 31, 2015
SECTION A- PROPERTY INFORMATION FOR INSURRNCE COMPANY USE
� A7. Building OwnePs Name BURCHENAL Policy Numbee
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box Na Company NAIC Number.
.t058 ELDORADO AVENUE
- City CLEARWATER BEACH State FL ZIP Code 33767
A3. Property Description (Lot and Blodc Numbers, Tax Parcel Number, legal Description, etc.)
LOT 4 AND NORTH 1/2 OF LOT 3, BLOCK "70" , MANDALAY
A4. Building Use (e.g., Residential, Non-Residential, Addition, Aocessory, etc.) RESIDENTIAL
A5. Latitude/Longitude: Lat. Long. Horizontal Datum: ❑ NAD 7927 � NAD 1983
A6. Attach at least 2 photographs of the building if th�: Cert�cate is being used to obtain flood insurance.
A7. Building Diagram Number 1 B
A8. Por a building with a crawlspace or enclosure(s): A9. For a buildinc� ��rith an attached garage:
a) Square footage of crawlspace or enGosure(s; sq ft a) Square footage of attached garage sq ft
b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage
or enclosure(s) within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade
c) Total net area of flood openings in AB.b sq in c) Total net area of flood openings in A9.b sq in
d) Engineered flood openings? ❑ Yes ;] No d) Engineered flood openings? ❑ Yes ❑ No
SECTION B- i=LOOD INSLlRANCE RATE MAP (FIRM) INcQRMATION
B1. NFIP Community Name 8� Community Number
CLEARWATER 125096
62. County Name
PINELLAS
B3. State
FL
; 64: Map/Panel Number B5. Suffix B6. FlRrvt Index Date B7. FIRM Panel 68. Flood B9. Base Flood Elevation(s) (Zone
1'2103C0064 G 9-03-03 Effective/Revised Date Zone(s) AO, use base flood depth)
, 9-03-03 "VE" 13.0
614. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item 69.
.- ❑ FIS Profile � FIRM ❑ Community Determined ❑ OtheNSouroe:
B1�1: :�Indiaate e;avation datum used for BFE in Item B9: ❑ NGVD 1929 � NAVD 1988 ❑ C�ther/Source:
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Othervuise Proteded A;�a (OPA)? ❑ Yes � No
Designation Date: ❑ CBRS ❑ OPA
SECTION C- Bt3��l.DING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ❑ Const�uction Drawings' ❑ Building Under Consfr`uction" � Finished Construction
'A new Elevation Certificate will be required when �•.mstrudion of the building is complete.
:r G2. Elevations - Zones A1 A30, AE, AH, A(with BFE), VE, W-V30, V(with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AH, AR/AO. Complete Items C2.a-h
below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.
Benchmark Utilized: CLEARWATER I-2 ELEV. 4.�;. Vertical Datum: NAVD'88
Indicate elevation datum used for the elevations in ,Cems a) through h) below. ❑ NGVD 1929 � NAVCa 1988 ❑ OthedSource:
Datum used for building elevations must be the same as that used for the BFE.
Check the measurement used.
a) Top of bottom floor (including basement, crawlsF:ace, or enclosure floor) 8.26 � feet ❑ meters
b) Top of the next higher floor N/A. ❑ feet ❑ meters
� c) Rottom of the lowest horizontal structural membe •(V Zones only) N/A. ❑ feet ❑ meters
i' ,d) Attached garage (top of slab) 4.95 � feefi ❑ meters
e) Lowest elevation of machinery or equipment ser.��cing the building
(Describe rype of equipment and location in Corr,ments) -- ❑�t ❑ meters
� � Lowest adjaceM (finished) grade next to buildin5 (LAG) 5.2 � feet ❑ meters
g) Highest adjacent (finished) grade neut to buildinc; (HAG) 6_0. � feet ❑ meters
h) Lowest adjacent grade at lowest elevation of der.�. or stairs, including structural support NlA. ❑ feet ❑ meters
SECTION D- SIf�ZVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
� ,!^..�fYS)I11 e '.
- This certification is to be signed and sealed by a land surveyor, engineer, or archited authorized by law to certify elevation � "'�
information. I certify that the infoimation on this Cerfificate represe�rts my best e1%rts to inte�pret the data P•lailable. ' 1�`` ••••
I understand that any fa/se stafement may be punishat'e by fine or imprisonment under 18 U S. Code, Sec. �on 1001. :� c�, ,� �G`•,� r.�� ,��:,
❑ Check here if comments are provided on badc of f��rn. Were latitude and longitude in Section A provided by a �:= :'r�: «���. ;
� Check here if attachments. Iicensed land surveyor? � Yes ❑ No "`" �� �a' � �;�:�
Certifier's Name WILLIAM C. KEATING
', Titte LAND SURVEYOR
Address 1275�1 ,�1
--� �
, Signaturelr
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License Number 1528
Companj+ Name ALLIED SURVEYING
AV j�' City CLE,4RWATER State FL ZIP Code 33755
Date 5- i-15 TE L 7 2 7-
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-1263
See reverse side for continuation.
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Replaces all previous editions.
r� ��VATION CERTIFICATE, page 3 Buiiding Photograph�
See Instructions for Item A6.
IMPORTANT: In these spaces, copy the �erresponding information from Section A.
Building Street Address (including Apt., Unit, Su:te, ?nd/or Bldg. No.) or P.O. Route and Box No.
1058 ELDORADO AVENUE
City
- CLEARWATER BEACH FLORIDA �� 767 Z1PCode
FOR INSURANCE COMPANY:USE
: rvucy ryumoer.,
Company NAIG Num6er: ;
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If using the Elevation Certificate to obtain n,=1P flood insurance, affix at least 2 buiiding photographs below according to the instructions
for Item A6. Identify all photographs with aa�e taken; "Front vew° and "Rear View"; anc:, if required, "Right Side VevW' 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 Fhotographs than witl fit on this page, use the Continuation Page.
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PICTi7RES TAKEN
REAR VIEW
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MAY 14-, 2015
FEMA Form 086-0-33 (7/12) Replaces all previous editions.
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