711 BAY ESPLANADE«
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i'�uc�r+� _'x+�^nGENCY h"ANAG�'.'iG►�IT L►GENi.Y
r-" � F OOD INSURANCE PROGRAM
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Th�s form is to be ussd tor: t) NewiEmergency Program construcUOn in Special Flood Hazard Areas, 2) Pre-FIRM construcUon after
September 30, 1982; 3) Post-FIRM construct�on: and, 4) Other build� gs rat�� ost-FIRM rules.
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BUI�DING OVJNER'S """"""'
NAME
THnh1AS t5" F i I�A F RFNNFTT 71 1 RAY FSPI ANAI�F ('l EARI�ATFR 6EACH, FLORIDA
PROPERTY LOCATION (Lot and Block numbers and address it available) FLOR I DA
LOT 3, BLOCK 35 MANDALAY SUBDIVISION 711 BAY ESPLANADE, CLEARWATER BEACH,
fI certify inat ine inio�mavon on this cert�ficate represents my best efforts to interpret the data available. i understand that any false
istatemen; may be punishable by t�ne or �mpnsonment under 18 U.S code, Section 1001.
1 SECTION 1 ELIGIBILITY CERTIFICATION (Completed by Local Community Permit Otficial or a Registered Professional Engineer,
Architect. or Sur�eyor)
COMh9UNITV NO PANEL NO SUFFUC DATE OF FIRM FIRM ZONE DATE OF CONSTR. 'IBASOE��LOODe �Pth) BUILDING �S ❑ NBwlEmOrgenty
7 J UNE 1� O Pre-FIRM Reg. I
125096 �001— 10.QQ FEET �Post-FIRMReg
1983 A-12
YES NO �t �s intended that the building described above will be constructed in compliance with the community's flood plain
G ❑ ordinance. The fteNGVD Failure �o co struct t e bu d ng at th s elevat�on'may pla9e the bu Idingli bviolat on'of ation
ot "
the community's flood plain management ordinance.
YES NO The building described above has been constructed in compiiance with the community's flood plain management
� C7 ordinance based on elevation data and visuat inspection or other reasonable means.
If NO is checked, attach copy of variance issued by the community. �
YES NO The mobile home localed at the address described above has been tied down (anchored) in compliance with the _
p ❑ community's flood plain management ordinance, or in compliance with the NFIP Specifications.
'� MOBILE HOME MAKE MODE� YR. OF MANUFACTURE SERIAL NO. DIMENXIONS
(Community Permit Official or Registered Professional Engineer, Architect, or Surveyor)
NAME
TITLE
CITY STATE Z�P
SIGNATURE DATE PH N •' -
SECTION Il ELEVATION CERTIFiCATION (Certified by a local Community Permit Official or a Registered Professional Engineer, `
" Architect, or Surveyor.)
FIRM ZONE A1-A30: I certify that the b ildin at the property location described above has the lowest lloor (including basement)
at an elevation of�feet. NGVD (mean sea Ievel) and the average grade at the building site is at
an elevation of L��—feet, NGVD.
FIRM ZONES V, V1-V30: I certify that the building at the property location described above has the bottom of the lowest /loor beam
• at an elevation of feet, NGVD (mean sea level), and the average grade at the building site
is at an e�evation of feet, NGVD.
FIRM ZONES A, A99, AO. AH, and EMERGENCY PROGRAM: I certity that the building at the property location described above
has the lowest floor elevation of feet. NGVD. The elevation of the highest adjacent grade next
to the building is -feet. NGVD.
SECTION III FIOODPROOFING CERTIFICATION (Certification by a Registered Professional Engineer or Architect)
I certify to the best o! my knowledge, information, and betief, that the building is designed so ihat the building is watertight, with
walls substantially impermeable to the passage of water and structural components having the capability of resisting hydrostatic
a�d hydrodynamic loads and effects ot buoyancy that would be caused by the flood depths, pressures velocities, impact and uplift
forces associated with the base flood. "
YES rJ NO � In the event ot flooding, will this degree of floodproofing be achieved with human intervention?
(Human intervention means that water will enter 3he building when floods up to the base flood leve! oc-
cur unleas rneasures are taken prior to the flood to prevent entry of water (e.g., bolting metal shields over
doors and windows). - .
YES '= NO '� Will the building be occupied as a residence?
+t .r.e 3:�sv.•<_� tc bc•.h q�cs.;�ns is YFS, the floodproofing cannot be credited for rating purposes and the actual lowest floor must be
completed and certif�ed instead. Complete both the elevation and floodproofing ce�tificates.
FIRM ZONES A, At-A30. V1-V30, AO and AH:
THIS CEftTIFICATION IS FOR �(SECTION 1�
CERTIFIER'S NAME
Certified Floodproofed Elevation is 4eet, (NGVO).
❑ BOTH SECTIONS II AND III (Check One)
COMPANY NAME LICENSE NO. (or Affix Seal)
GEORGE A. SHIMP II GEORGE A. SHIMP II � ASSOC. INC. #2512
TITLE ADQAESS � Z��
PRESIDE�JT 3211 U.S. A�T. 19 NOl2TH, SUITE B 33563 �
(STATE PHONE �
, SIG�tiATyF,c D�',Tc CITY
i i��.r/ ����j� 241 1984 PALM HARBOR, FLORIDA 784-5496
! _ ���_ � � ---
� / T`�:� i,-�surance �`''�,�� attach !he originaf copy of the completed form to the tlood msurance pol�cy appUcation,
� the second copy should be suppiied to the policyholder and the third copy retained by the agent
f INSURANCE AGENTS MAY ORDER THlS FORM 593-117
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-�E^ �-��-T ��.^. Q�3 R� F_FLtL_ _S FEM1"P FORM581-91T1 A�JD87-10(T). FEB 8U, WHICH ARE OBSOLET .