106 MIDWAY ISLANDU.S.DEPAR7INENTOFHOMELANDSECURITY ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program Important: Read the instructions on pages 1-9.
SECTION A - PROPERTY INFORMATION
A1. Buiiding Owner's Name KASSEL EQUITY GROUP, TPA
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.
106 MIDWAY ISLAND
City CLEARWATER
State FL ZIP Code 33767
OMB No. 1660-0008
Expiration Date: July 31, 2015
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
UNIT 3 ISLAND ESTATES OF CLEARWATER, LOT 86, P.B. 47, PG. 62
A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) RESIDENTIAL
A5. Latitude/Longitude: Lat. N-27-58-39.4 Long. W-82-48-45.0 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. Buiiding Diagram Number 1A
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) N/A sq ft a) Square footage of attached garage 506 sq ft
b) Number of permanent flood openings in the crawispace b) Number of permanent flood openings in the attached garage
orenclosure(s) within 1.0 foot above adjacent grade N/A within 1.0 foot above adjacent grade Q
c) Total net area of flood openings in AB.b N/A 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
CITY OF CLEARWATER 125096 PINELLAS
B4. Map/Partel Number B5. Su�x B6. FIRM Index Date 67. FIRM Panel
12103C0102 G 8/18/2009 Effective/Revised Date
9/3/2003
B3. State
FLORIDA
B8. Flood 69. Base Flood Elevation(s) (Zone
Zone(s) AO, use base flood depth)
AE 11'
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in item 69.
❑ FIS Profile � FIRM ❑ Community Determined ❑ Other/Source:
B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source:
612. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?
Designation Date: ❑ CBRS ❑ OPA
❑ Yes � No
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, ARlAO. Complete Items C2.a-h
below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.
Benchmark Utilized: PIN CO DISK AURAL A Vertical Datum: ELEV=11.82 NAVD1988
Indicate elevation datum used for the efevations in items a) through h) below. ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source: o� o�'�
Datum used for building elevations must be the same as that used for the BFE. ����i �
a) Top of bottom floor (including basement, crawlspace, 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)
� 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
6.1
N/A.
N/A.
5.4
6.1
4.9
5.4
N/A.
Check the measurement us�
� feet ❑ meters
❑ feet ❑ meters
❑ feet ❑ meters
� feet ❑ meters
� feet ❑ meters
� feet ❑ meters
� feet ❑ meters
❑ feet ❑ meters
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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 .:rz-
information. 1 certify that the information on this Certi�cate represents my best efforts to interpret the data available. ���''�
l understand that any false statement may be punishab/e by flne or imprisonment under 18 U. S. Code, Section 1001. a�! ,,`�� ..
� ��,
� Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a :�.,�".��'�y!��� '�`i ;
IRI ('har.k hare if akachmpnfc Ii�e.,�vA ��.,.� ���..�e.....� RI ve� I"1 ��.. � �
Certifier's Name LAUREN PENNY, P.S.M.
Title LAND SURVEYOR
Address 10730 102"" AVE. N. UNIT A
Signature �0,,,___ Q _
License Number #4931
Company Name L. R. PENNY AND ASSOCIATES, INC.
City SEMINOLE State FL ZIP Code 33778
Date 10/09/2015 Telephone 727-398-4360
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FEMA Form 086-0-33 (7/12) See reverse side for continuation. Replaces all previous editions.
r
ELEVATION 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.
106 MIDWAY ISLAND
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 C2.e): LOWEST EQUIPMENT IS AN AIR CONDITIONER. LATITUDE LONGITUDE AQUIRED FROM GOOGLE EARTH. ELEVATIONS
DETERMINED USING GPS METHODOLOGY.
Signature Date 10/09/2015
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, crawlspace, 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 Q 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.
Property Owner's or Owner's Authorized Representative's Name
Address
Signature
Comments
City
Date
State
Telephone
ZIP Code
Check here if attachments.
SECTION G — COMMUNITY INFORMATION (OPTIONAL)
The local o�cial 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 officiai compieted 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: ❑ feet ❑ meters
G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters
G10. Community's design flood elevation: ❑ feet ❑ meters
Local Official's Name
Community Name
Signature
Comments
Title
Telephone
Date
Datum
Datum
Datum
Check here if attachments.
FEMA Form 086-0-33 (7/12) Replaces ali previous editions.
EL'EVATI�N CERTIFlCATE, page 2
IMPORTANT. ln these spaces, copy the corresponding informatian from Section A.
�uifding Street Address (incfuding Apt., Unit, Suite, and/or Bidg. No.) or P.O. Route and Box No.
1Q6 MIDWAY ISLAND
City CLEARWATER State FL Z!P Code 33767
SECTION D— SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION (CONTlNUED)
Copy both sides of this Elevation Certificate for (1) community o�cial, (2) insurance agenVcompany, and (3) building owner.
Comments C2.e): LOWEST EQUIPMENT IS AN AIR COND{TIONER. LATITUDE LONGITUDE AQUIRED FROM GOOGLE EARTH. EI.EVATIONS
DETERNi1NED USING GPS METHODOLOGY.
5ignature
Date 10/09/2015
SECTION E— BUILDING ELEVATION INFORMATION (SURYEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE), compiete Items E1—E5. If the Certificate is intended to support a LOMA or LOMR-F request, complete Sectior►s A, B,
and C. For Items E1—E4, use naturai grade, if availabie. Check the measurement used. In Puerto Rico only, enter meters.
E1. Provide elevation information fpr the faUawing 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 battom floor (inGuding basemeni, crawlspace, or enclosure} is p feet ❑ meters � above or � befow the HAG.
b} Tap of bottom floor (inGuding basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ befow 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 Instructio�s), 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 andlor equipment servicing the building is ❑ feet ❑ meters ❑ above or � below the HAG.
E5. Zone A� only: If no flood depth number is available, is the top of the bottom floor elevafed in accordance with the community's floodpfain management
ordinance? Q Yes ❑ No ❑ Unknown. The local o�cial must certify this infortnation in Section G.
SECTION F— PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property owner or owner's autfiorized 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 5ections A, B, and E are correct to the best of my knowledge.
Property Owner's or Qwne�'s Authorized Representative's Name
Address
Signature
Comments
City
Date
State
Telephone
ZIP Gode
Check here if attachmertis.
SECTtON G — GOMMUNITY INFORMATION (OPTIONAL)
The lac�al official who is authorized by law or ordinance to administer the cammunity's floocfplain management ordinance can complete Sections A, B, C(or E), and G
of this Elevation Gertificate. Complete the applicable �em(s) and sign below. Chedc the measurement used in Items G8-1�10. tn Puerto Rico onty, 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 arehitect who
is authorized by taw to certify elevation info�rnation. (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 Zo�e AO.
G3. ❑ The following information (Items G4-G10) is provided for community floodplain management purposes.
G4. Permit Number G5. Date Permit Issued G6. Date Cert�cate Of Comptiance/Occupancy Issued
G7. This permit fias been issued for: � New Construction ❑ Substantial tmprovement
G8. Elevation of as-buiR lowest floor (including basementy of the building: ❑ feet ❑ meters
G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters
G10. Community's design flood e�vation:
Local Official's Name
Community Name
Signature
Comments
FEMA Form 086-0-33 (7/12)
❑ feet ❑ meters
Title
Telephone
Date
Datum
Datum
Datum
Check here if attachments.
Replaces all previous editions.
ELEVA�lON CERTIFICATE, page 3 guilding Photographs
See Instructions for ltem A6.
tMPORTANT: In these spaces, copy the correspanding information from Section A. 1=4����"�,��
Buiiding Street Address (inGuding E1pt., Unit, Suite, and/or Bk1g. No.} or P.O. Route and Box No. �(�� ��
1d6 MIDWAY ISLAfVD
City CLEARWATER State FL ZIP Code 33767 �;�str�ar�a tit�cs
ff using the Elevation Certificate to obtain NFtP 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, photagraphs must show the ioundation with representative examptes of the flaod openings or vents, as
indicatECi rn Section A8. If submitting more photographs than will fit on this page, use the Continuation Page.
SEE ATTACHED SHEET OF PHOTOGRAPHS
FEMA Form Q$6-0-33 (?t12) Replaces all previous editions.
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