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430 PALM ISLAND SEU.S.DEPARTMENTOFHOMELANDSECURITY ELEVATION CERTIFICATE FEDERAL EMERGENCY MANAGEMENT AGENCY National Flood Insurance Program Important: Read the instructions on pages 1-9. SECTION A - PROPERTY INFORMATION A1. Building Owner's Name Elba I. Maslowski Trust A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. 430 Palm Island Southeast City Clearwater State FL ZIP Code 33767 A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) Lot 29, Island Estates of Clearwater Unit 6-A OMB No. 1660-0008 Expiration Date: July 31, 2015 A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) Residential A5. Latitude/Longitude: Lat. 27.9846325 Long. -82.8148499 Horizontal Datum: ❑ NAD 1927 � 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 1 B A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) N/A sq ft a) Square footage of attached garage 484 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 0 within 1.0 foot above adjacent grade 0 c) Total net area of flood openings in A8.b 0 sq in c) Total net area of flood openings in A9.b 0 sq in d) Engineered flood openings? ❑ Yes � No d) Engineered flood openings? ❑ Yes � No SECTION B- FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 61. NFIP Community Name & Community Number B2. County Name B3. State City of Clearwater 125096 Pinellas FL 64. Map/Panel Number 65. Suffix B6. FIRM Index Date 67. FIRM Panel 68. Flood B9. Base Flood Elevation(s) (Zone 12103C0102 G 9-3-03 Effective/Revised Date Zone(s) AO, use base flood depth) 9-3-03 AE 11' 610. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9. ❑ FIS Profile � FIRM ❑ Community Determined ❑ OtheNSource: _ B11. Indicate elevation datum used for BFE in Item 69: ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal 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 construction of the building is complete. 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/AO. Complete Items C2.a-h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters. Benchmark Utilized: CITY OF CLWR BM H-4 Vertical Datum: ELEV= 4.4997' (N.A.V.D.� Indicate elevation datum used for the elevations in items a) through h) below. � NGVD 1929 � NAVD 1988 � OtherlSource: Datum used for building elevations must be the same as that used for the BFE. a) Top of bottom floor (including basement, crawlspace, or enclosure floor) b) Top of the ne� 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) fl Lowest adjacent (finished) grade ne� 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 7.39 N.A N.A 6.79 6.91 6.5 6.8 N.A Check the measurement used. � feet ❑ meters � feet ❑ meters � feet ❑ meters � feet ❑ meters � feet ❑ meters � feet ❑ meters � feet ❑ meters � feet ❑ 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. 1 certify that the information on this Certificate represents my best efforts to interpret the data availab/e. I understand that any false statement may be punishable by fine or imprisonment under 18 U. S. Code, Section 1001. � Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a � Check here if attachments. licensed land surveyor? � Yes ❑ No Certifier's Name Philip C. Stock Title President Address 516 Lakeside Place (f �� .�,%.e�� Signature License Number RLS#3035 Company Name Target Land Surveying City Largo State FL ZIP Code 33771 Date 1-12-13 Telephone (727) 784-0573 q ,. ���H v����� (/�u.Q,� L° -�� FEMA Form 086-0-33 (7/12) See reverse side for continuation. Replaces all previous editions. � cLEVATION CERTIFICATE, page 2 IMPORTANT: In these spaces, copy the corresponding information from Section A. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. 430 Palm Island Southeast City Clearwater State FL ZIP Code 33767 SECTION D— SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenUcompany, and (3) building owner. Comments Job #140109.02 C2.e= A/C Unit Signature ��� �� Date 1-12-13 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 LOMR-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 enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the HAG. b) Top of bottom floor (including basement, crawispace, 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 building is ❑ 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) CERTIFICATION 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. PropeRy Owner's 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 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 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 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 AO. G3. ❑ The following information (Items G4—G10) 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: G9. BFE or (in Zone AO) depth of flooding at the building site: G10. Community's design flood elevation: Local Official's Name Community Name Signature Comments ❑ feet ❑ meters Datum ❑ feet ❑ meters Datum ❑ feet ❑ meters Datum Title Telephone Date Check here if attachments. FEMA Form 086-0-33 (7/12) Replaces all previous editions. r ELEVATION CERTIFICATE, page 3 guilding Photographs See Instructions for Item A6. IMPORTANT: In these spaces, copy the corresponding information from Section A. Building StreetAddress (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. 430 Palm Island Southeast City Clearwater State FL ZIP Code 33767 FOR INSURANCE COMPANY USE Policy Number: Company NAIC Number: 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 Viev✓' 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 flood openings or vents, as indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page. "Front view" "Rear view" FEMA Form 086-0-33 (7/12) Replaces all previous editions. ELEVATION CERTIFICATE, page 4 guilding Photographs Continuation Page IMPORTANT: In these spaces, copy the corresponding information from Section A. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. 430 Palm Island Southeast City Clearwater State FL ZIP Code 33767 FOR INSURANCE COMPANY USE Policy Number: Company NAIC Number: If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date taken; "Front VievJ' and "Rear View"; and, if required, "Right Side VievJ' 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. Left side view Right side view FEMA Form 086-0-33 (7/12) Replaces all previous editions.