JEWEL ST J�'�/jyr�'�ht ' �'� . •
y �'�����H�ELEVATION CERTIFiCATE O.M.B.No3067 0077
���% �f"��� Exprres May 31, 1993
�- �'� FEDERAL EMEAGElJCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANC� PROGRAM
• ATTENTION: Use of this cercilicate does not provide a waiver ot the Ilood insurance purchase reouirement. Ti�is form�s used only to
�:ovide eievation information necessary lo ensure comptiance with applicable community floodplam management ordinances. to
�elermme ihe proper+nsurance premium rate. ano/or;o support a request for a Letter o(Map Amenoment or Revis�on �LOMl1 or�OMFI.
Instructions tor compteting this form can be found on the loilowing pages.
SECTION A PROPEqT'f INFORMATICN I F�7R INSURANC°__�'.�P�NV VSc j
�U'IOING C\VNER'S NAME POL�C'/NU�.tO�? I
� �-hn,�S � u � 12 �IN1 /a � �OU � _
;TiiF=_T aCDRESS Ilnciuoing Aat..Jnit.Suite anaor altlq.Vumoen OR P.O.nCJTc:tiNO BC:<VUMBER COMPANV NAiC':Ut.10ER J I
�
�TNER DESCR�PTION fLot�no 81ock Numoers.etc.: � �
_ LoT �t �l«.� �4 vY1Ps,,, tz� t A�.��D�Ui51o�J __
':TY Si\Tc i.IP CODE
C� I �A Q. i t� A-`I--ER �C..
SECTICN 8 FLOOD INSURANC� RATE MAP(FIRM) INFORMATION
=-�vide the roilowing from �he oro�er FiFM lSee.lnstruc:lonsl:
' t.COI.tr,nUNITY NUMBER 2.?ANEI NU:uIBER 9.SUFFIX = OATE OF=�FiM INDEX 5.PIRtd ZCNE 6.BASE=��OD ELEVATIO�
rin n0��nes.�se aeouii
12 � o� � �oo� D S !9 9 � A � i ( ,Q�
" ndicate the eievation datum system usea on the FIRM for 8ase Flood E'e�iations(BFE): ,r NGVD'29 _Olher fdescribe on oacxl
_. =or�ones A or V, where no BF'c is providea on the FiRM. ano;he community has establisl�ed a BFc tor Ihis buildino site. indica�e
�he community's BFE: .._ (eet NGVD ror other ��RM datum—see Section B. Item �1.
SECTION C BUII.DING ELE`/ATION INFORMATION
' Jsing the Elevation Certificate Instructions.indicatg the diagram number from the diagrams found on Pages 5 and 6 Ihat best
� .�escribes the subject building's reference level �O
_ al. FiRM Zones A1-A30. AE. AH, and A�with BFE'�. The top oi:he reierence level tloor from the selected diagram is at an elevanon
of ' � S.�O teet NGVD (or other FIRM datum—see Sec:ion B. Item 7).
bl:FIRM Zones V1-V30, VE, and V(with BFc). The bottom oi;he lowesi horizontai structural member of the reference Ievel from
lhe selected diagram, is at an elevation ot ._ feet NGVD lor other FIRM datum—see Section B, Ilem 7).
,c). FIRhA Zone A (without BFEj. The ftoor used as the reierence ievel(rom the selected diagram is ! �.�._;leet above _ or
below _ (check one) the highest grade adjacent to the buiiding.
,d). FIRM Zone AO. The floor used as the reference level irom the seiected diagram is : .,_ leel above� or below_' (check
one) the highest grade adjacenl lo the building. If no flood deplh number is available, is Ihe building's lowesl floor(reference
level) elevated in accordance with lhe community's floodplain management ordinance? �I Yes '� No `I�Unknown
3_ indicate the elevation datum system used in determining Ihe above reference level elevations:� NGVD'29 � Oiher(describe
under Commenis on Page 2). (NOTE: ll the elevalion datum used in measuring the elevalions is diNerent than that used on
the FlRM (see Seclion B, lfem 7], then convert fhe elevations to the dalum system used on Ihe FlRM and show the conversion
equalion under Comments on Page 2.J
�. Elevation reference mark used appears on FIRM: � Yes _ No (See Instructions on Page 4)
�. The reterence level elevation is based on: �actual construction _ construction drawings
(NOTE: Use ol construction drawings is only valid il the building does not yet have the re%rence level fJoor in place, in which
case this cerlilicafe will only be valid/or the building during the course ol consiruction. A post-consfrucfion E/evation Cerlilicate
will be required once consfruction is complele.J
t. The elevation of the Iowest grade immediately adjacent to the building is� � � � �.�'�� feet NGVD(or olher FIRM datum-see
Seclion B, Item 7).
SECTION D COMMUNITY INFORMATION �
• ' II the community otficial responsible (or veriFying building elevations specilies that the re(erence level indicaled in Seclion C, Ilem t
is not the "Iowest floor"as detined in lhe community's floodplain management ordinance, the elevation of the building's"lowest
. floor"as delined by the ordinance is: � � � � �._� feet NGVD(or olher FIRM datum—see Section 8, Item 7).
2_ Date of lhe start of construction or substanlial improvement .
FEMA Form 81-31�MAY 90 REPlACES AtL PREVIOUS EDITIONS SEE FEVERSE SIOE FOR CONTINUA710N
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' - � � -- . _ —-`_' SECTION E CEHTIFlCATION = _ ---.--_. � - - - .-
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Ttiis certificaiion is to be signed by a land surveyor, engineer,ar architect who is authorized by state or local law to certify elevation '
information when the elevation inlormation for Zones A1—A30,AE,AN,A(with 8FE),V1—V30,VE, and V(wilh BFE)is required.
Community o�cials who are authorized by local law or ordinance!o provide floodplain management information, may also sign the
certification. In the case of Zones AO and A(without a FEMA or wmmunity issued 8FE), a building official, a property owner,or an
owner's representative may also sign the certification.
Relerence level diagrams 6, 7 and 8 - Oistinguishing Features—I(the certifier is unable lo certity to breakaway/non-breakaway wall,
enctosure size, location ot servicing equipment, area yse, �all openings,or unfinished area Featu�e(s), then list the Feature(s) not
included in the certification under Comments Delow. The diagram number, Section C, Item 1, must still be entered.
I certily rha►the in/o�mation in Secrions B and C on lhis certilic�re�epresents my best eNoRS to inrerpre(Ihe data available.
1 unders�and lhat any lalse starement m.ay be pun�shable by Me o�imprisonmenr unde� 1B U.S. Code. Secrron 1001.
CERTIFIEA'S NAME �;, LIC�NSE NUMBER(or AH�x SeaQ
Ro,�a:c:'�.u,�,►-�,�,�-1 u�u-�es t�s� � 3 7¢7
TITLE ���'� 4 ,�, {„ ''�• COMPA Y NAME
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AOORESS ;.�, ' ' CITY STATE ZIP
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SIGNATURE �, f+ ' ' DATE PHONE g�� 4�7��b
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Copies should'be made of"ft3;►���Ce�'liiicate for: 1 ommunity official,2) insurance agenUcompany, and 3)build'Ing owner.
', '
COMMENTS: ` y.
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• Y ON , _ NlfR1 ON PILES, �
SlAB � � _ BASEMENT ' PIEHS.OR COWMNS
A V A A Y
� ZONES IONES ( 20NES ZONES ZONES
� _
' REFENENCE
PF=EREHCE � �� LEVEL REFERENCE
IFYEI . iLOOO IEVEt
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BASE L �'j.::.G '::::�•.if.�'_'�y.C�c:i'a BASE
�.�.,�.•..�: � REFEREIICE ��
fLOOD � •.�•: ::� A�JALEIfT �:.:,N lEVEI EIEVATIO�+
ELEVATiOn 6MDE "'y -
REFEREN�:E Api'GEtlf _y}.�, . .
LEYEL GAAOE
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Th�diagrams above illustrate the points at wk�ich the elevations should be measured in A Zones and V Zones. � � � - �
�levations tor all A Zones should be measured at the lop of the re(erence level(loor. . : . •
Elevalions for all V Zones should be measured at the bottom of the lowest horizontal structural member. •- � .
_ . . - . . . , . .. . . .. �
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