18675 US HWY 19 N #167 5.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008
ederal Emergency Management Agency Expires MarCh 31,2012
�ational Flood Insurance Program tmportant: Read the instructions on pages 1-9.
SECTION A-PROPERTY INFORMATION For Insurance Company tJse:
A1. Building Owner's Name JERRY CARROLL Poticy Number
A2. Buiiding Street Address(including Apt.,Unit,Suite,and/or Bidg.No.)or P.O.Route and Box No. Company NA1C Number
18675 US HIGHWAY 19 NORTH LOT 167
City CLEARWATER State FL ZIP Code 33764
A3. Property Description(Lot and Blodc Numbers,Tau Parcel Number,Legal Description,etc.)
PID 20-29-16-03290-000-1670
A4. Building Use(e.g.,Residential,Non-Residential,Add'Rion,Accessory,etc.)RESIDENTIAL
A5. Latitude/Longitude:Lat.27.943723DEG Long.-082.722162DEG 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 5
A8. For a building with a crawlspace or enGosure(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 N!A sq ft
b) No.of permanent flood openings in the crawlspace or b) No.of permanent flood openings in the attached garage
enclosure(s)within 1.0 foot above adjacent grade N/A within 1.0 foot above adjacent grade N/A
c) Total net area of flood openings in A8.b N/A sq in c) Total net area of flood openings in A9.b N/A sq in
d) Engineered flood openings? ❑ Yes � No d) Engineered flood openings? ❑ Yes � No
SEC710N B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
61. NFIP Community Name&Community Number B2.County Name B3.State
PINELLAS COUNTY 128139 PINELLAS FL
B4.Map/Panel Number B5.Suffix B6.FIRM Index 67.FIRM Panel B8.Flood B9.Base Flood Elevation(s}(Zone
12103C012$G G Date Effective/Revised Date Zone(s) AO,use base flood depth)
9/03/2003 9l03/2003 AE 9
610. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 69.
❑ FIS Profile � FIRM ❑ Community Determined ❑ Other(Describe)N!A
611. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 �I NAVD 1988 ❑ Other(Describe)W/A
B12. ts the building located in a Coastal Barrier Resources System(CBRS)area or Othervvise Protected A�ea(OPA)? ❑ Yes � No
Designation Date N/A ❑ CBRS ❑ OPA
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REG'�"" ,
C1. Building elevations are based on: ❑ Construdion Drawings"' ❑ Building Under Constn ,\ !'� � , ` ._._
*A new Elevation Certificate will be required when construction of the building is complete. �� � �, --� r ��'?�
C2. Elevations-Zones A1-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AWAE,AR/Ai� l� �.%�
below according to the buildir�g diagram specified i�Item A7. Use the same datum as the BFE.
Benchmark Utilized TIDEL 872 6689 2Vertical Datum NAVD88 R ��
ConversioNComments N/A � J} � ��Q
Check th `-�
a) 7op of bottom floor(including basement,crawlspace,or enclosure floor)9.2 �feet ❑rrH
b} Top of the next higher floor N/A. ❑feet ❑rrn
c) Bottom of the lowest horizontal structural member(V Zones only) N/A. ❑feet ❑m�
d) Attached garage(top of slab) N/A. ❑feet ❑rrN
e) Lowest elevation of machinery or equipment servicing the building 9.2 �feet ❑me
(Describe type of equipment and location in Comments)
� Lowest adjacent(finished)grade ne�ct to building(LAG) 5.3 �feet ❑me
g) Highest adjacent(finished}grade next to building(HAG) 6.7 �feet ❑me
h) Lowest adjacent grade at lowest elevation of deck or stairs,including 4.4 �feet ❑me
structural support
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERT.. ._.....,..
This certification is to be signed and sealed by a tand surveyor,engineer,or architect authorized by law to certify elevation
information. I certify that the information on this Cert�cate represerrts my best efl`orts to interpret the data available.! " �� F,
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 �`,��; ,����" „ �`o- 4 .
licensed land surveyor? � Yes ❑ No d '��' � � '
���` � `� ° t
Cert�er's Name JOHN H.REHFELT License Number LS3566 �,.x; „ . ..�:3:
�
Title VP Company Name C&J SURVEYWG,INC. � ������ �#
� ,;�, ��;x,,
Address 5202 RAWLS ROAD City TAMPA State FL ZIP Code 33624 ;� . �'�,s. :",,, `` �' :
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Signa J . � Date 7/07/2011 Telephone 813-963+2250 ' ��„� i � �"�' :r�,,
� .� ,��
FEMA orm 81-31, Mar 09 See reverse side for continuation. Replaces all previous'editic�ns
� �-- - __ __
�PORTANT: In these spaces,copy the corresponding information from Section A. For fnsurance Company Use:
_ -
- __ __ - -_
3uilding Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. o icy um er
18675 US HIGHWAY 19 NORTH LOT 167
,` City CLEARWATERState FL ZIP Code 33764 Company NAIC Number
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Cert�cate for(1)community official,(2)insurance agenUcompany,and(3)building owner.
Comments 1.)COPIES NOT VALID UNLESS ALL 4 SHEETS ARE EMBOSSED WITH MY SURVEYORS SEAL.
2.)OUR JOB#IS 11069
C2-E THE AIC PAD WAS USED FOR THIS ELEVATION.
C2-H THE GROUBD AT THE REAR STEPS WAS USED FOR THIS ELEVATION
C2-C T ELEVATI OF T E M BOTTOM IS AT 7.6
Signatu J E Date 7/07/2011
❑ Check here if attachments
SE N 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 irtformation 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 enGosure)is . ❑feet ❑meters ❑above or❑ below the IAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages&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 platforrn of machinery and/or equipment servicing the building is ❑feet ❑meters ❑above or[j 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 Sedions A,B,and E are correct to the best of my knowledge.
Property Owner's or Owner's Authorized Representative's Name
Address City State ZIP Code
Signature Date Telephone
Gomments
❑Chedc here ff attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain managemerrt ordinance can complete Sections A,B,C(or E),
and G of this Elevation Certificate. Complete the applicable item(s)and sign below. Chedc the measurement used in Items G8 and G9.
G1.❑ The infortnation 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 inforrnation. (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-G9)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(PR)Datum
G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters(PR)Datum
G10.Community's design flood elevation ❑feet ❑meters(PR)Datum
Local OfficiaPs Name T��
Community Name Telephone
Signature Date
Comments
❑Check here if attachments
FEMA Form 81-31, Mar 09 Replaces all previous editions
Building Photographs
See Instructions for Item A6.
For Insurance Company Use:
Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Poiicy Number
18675 US HIGHWAY 19 NORTH LOT 167
Clty CLEARWATER S�t2 FL ZIP COd@ 33764 Company NAIC Number
If using the Elevation Certi�cate to obtain NFIP flood insurance, affix at least two 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." If submitting more photographs than will fit on this page, use the Continuation Page,
following.
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For Insurance Company Use:
Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No. Poiicy tvumber
18675 US HIGHWAY 19 NORTH LOT 167
Clty CLEARWATER State FL ZIP COd2 33764 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 View"and "Rear View°; and, if required, "Right Side View" and"Left Side View."
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/U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008
Federal Emergency Management Agency Expires March 31,2012
National Flood Insurance Program Important: Read the instructions on pages 1-9.
SECTION A-PROPERTY INFORMATION For Insurance Company Use:
A1. Building Owner's Name JERRY CARROLL Policy Number
A2. Building Street Address(inciuding Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number
18675 US HIGHWAY 19 NORTH LOT 167
City CLEARWATER State FL ZIP Code 33764
A3. Property Description(Lot and Block Numbers,Ta�c Parcel Number,Legal Description,etc.j
PID 20.29-16-03290-000-1670
A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)RESIDENTIAL
A5. Latitude/Longitude:Lat.27.943723DEG Long.-0$2.722162DEG Horizontal Datum: ❑ NAD 1927 � NAD 1983
A6. Attach at teast 2 photographs of the building if the Certifipte is being used to obtain flood insurance.
A7. Building Diagram Number 5
A8. For a building with a crawlspace or enGosure(s): A9. For a building with a�attached garage:
a) Square footage of crawlspace or enclosure(s) WA sq ft a) Square footage of attached garage N/A sq ft
b) No.of permanent flood openings in the crawlspace or b) No.of pertnanent flood openings in the attached garage
enclosure(s)within 1.0 foot above adjacent grade N/A within 1.0 foot above adjacent grade N/A
c) Total net area of flood openings in A8.b N/A sq in c) Total net area of flood openings in A9.b N/A sq in
d) Engineered flood openings? ❑ Yes � No d) Engineered flood openings? ❑ Yes � No
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP Community Name&Community Number 62.County Name B3.State
PINELLAS COUNTY 128139 PINELLAS FL
64.Map/Panel Number 65.Suffix B6.FIRM Index B7.FIRM Panel B8.Flood B9.Base Flood Elevation(s)(Zone
12103C0128G G Date Effedive/Revised Date Zone(s) AO,use base flood depth)
9/0312003 91�3/2003 AE 9
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 89.
❑ FIS Profile � FIRM ❑ Community Determined ❑ Other(Describe)N/A
B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 � NAVD 1988 ❑ Other(Describe)N!A
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes � No
Designation Date N!A ❑ CBRS ❑ OPA
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
Ci. Building elevations are based on: ❑ Co�strudion 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,AM,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. Use the same datum as the BFE.
Benchmark Utilized TIDEL 872 6689 2Vertical Datum NAVD88
Conversion/Comments N/A
Chedc the measurement used.
a) Top of bottom floor(including basement,crawlspace,or enclosure floor)9.2 �feet ❑meters(Puerto Rico only)
b) Top of the next higher floor �. ❑feet ❑meters(Puerto Rico only)
c) Bottom of the lowest horizontal structural member(V Zones only) N/A. ❑feet ❑meters(Puerto Rico only)
d) Attached garage(top of slab) NIA. ❑feet ❑meters(Puerto Rico only)
e) Lowest elevation ot machinery or equipment servicing the building 9.2 �feet ❑meters(Puerto Rico only)
(Describe rype of equipment and location in Comments)
� Lowest adjacent(finished)grade next to building(LAG) 5.3 �feet ❑meters(Puerto Rico only)
g) Highest adjacent(finished)grade next to building{HAG) 6.7 �feet ❑meters(PueRo Rico only)
hj �awest adjacent grade at lowest elevation of dedc or stairs,including 4.4 �feet ❑meters(Puerto Rico only)
structural support
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERtIFICATION
This ceRification is to be signed and sealed by a land surveyor,engineer,or architec�authorized by law to certify elevation •�-%��.
information. 1 certify that the infoimallon on this Cert�cate represents my best efforts to interpret the data availab/e.l �C� y..�
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 forrn. Were latitude and tongitude in Section A provided by a ���xa� �� �^ •
licensed land surveyor? � Yes ❑ No � �°� . ��a���`� �
Certifier's Name JOHN H.REHFELT License Number LS3566 �`�f��v� ��� -
.
'�;
Title VP Company Name C 8 J SURVEYING,INC. �``�
�,�-
Address 5202 RAWLS ROAD City TAMPA State FL ZIP Code 33624 .�
��.�;
Signat e JO T Date 7/07/2011 Telephone 813-963+2250 F .�' �-.� y
��.
� � _� , �
FEMA F 81-31, Mar 09 See reverse side for continuation. Replaces all previous edi�iow5
IMPORTANT: In these spaces,copy the corresponding information from Section A. For Insurance Company Use:
Building Street Address(inciuding Apt., Unit,Suite,and/or Bidg.No.)or P.O.Route and Box No. PoliCy Number
18675 US HIGHWAY 19 NORTH LOT 167
Gity CLEARWATERState FL ZIP Code 33764 Company NAIC Number
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agenbcompany,and(3)buitding owner.
Comments 1.)COPIES NOT VALID UNIESS ALL 4 SHEETS ARE EMBOSSED WITH MY SURVEYORS SEAL.
2.)OUR JOB#IS 11069
C2-E THE A/C PAD WAS USED FOR THIS ELEVATION.
C2-H THE GROUBD AT THE REAR STEPS WAS USED FOR THIS ELEVATION
C2-C TH LEV N E M BOTTOM IS AT 7.6
Signature Date 7/07/2011
❑ Check here if attachments
SEC ON 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 ❑fee# ❑meters ❑above or[]below the HAG.
E5. Zone AO only: If no flood depth number is availabte,is the top of the bottom floor elevated in accordance with the community's 800dplain management
ordinance? ❑Yes ❑ No ❑ Unknown. The tocal official must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTA7IVE)CERTIFICATION
The properry 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,8,and E are comect to the best of my knowledge.
Property Owners or Owner's Authorized itepresentative's Name
Address City State ZfP Code
Signature Date Telephone
Comments
❑Chedc here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain manageme�rt ordinance can complete Sections A,B,C(or E),
and G of this Elevation Certificate. Complete the applicable item(s)and sign below. Chedc the measurement used in Items G8 and G9.
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 certity 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 inforrnation(Items G4-G9)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(PR)Datum
G9. BFE or(in Zone AO)depth of flooding at the building s�e: � ❑feet ❑meters(PR)Datum
G70.Community's design flood elevation ❑feet ❑meters(PR)Datum
Local Official's Name Title
Community Name Telephone
Signature Date
Comments
❑Check here if attachments
FEMA Form 81-31,Mar 09 Replaces all previous editions
_
.
� Building Photographs
See Instructions for Item A6.
For insurance Compa�y Use:
Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No. Porcy Number
18675 US HIGHWAY 19 NORTH LOT 167
Clty CLEARWATER State FL ZIP COd2 33764 CompanyNAlCNumber
tf using the Elevation Certificate to obtain NFIP flood insurance, affix at least two 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." If submitting more photographs than will fit on this page, use the Continuation Page,
following.
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. ' Building Photographs
� Continuation Page For Insurance Company Use:
Building Street Address(including Apt,Unit,Suite,and/or Bldg. No.)or P.O. Route and Box No.
Policy Number
18675 US HIGHWAY 19 NORTH LOT 167
Cornpany NAIC Number
CItY CLEARWATER State FL ZIP COde 33764
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photographs with: date taken; "Front View and
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