36 WINDWARD IS - _ _, _ _
813 449 2778 P.03
Apr�. 22-98 03 : 18P POLARIS SURVEYING O.MB.NO. 3067•0077
?� � ELEVATION CERTIFICATE E�`'�'""°''3','�6
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FIOOD INSURANCE PROGI�AM
ENTION: Use of this certi(icate does not provide a waiver ot the tlood insurance purchase requiremenl. This form is used only to
ti�de elevation information necessary to ensure compAance with applicable community itoodplain management ordinances,to
etermine the proper insurance premium rate,and/or to support a request tor a Letler of Map Amendment or Revision(LOMA or LOMR).
Instructlons tor complstln�thls form can be tound on the followtng pages.
SECTION A PROPERTY INFORMATION FOR INSURANCE COMf'AM`I USE
� PO�ICY NUMBER
BUILDING OWNER'S NAME c C A F F IJ ER
.��-�__�••�..��� -- QpMPANY NAIC NUMBER- —
STAEET ADDRESS(Inc!udinq Apt.,UnK.SuMe anda B�dg.Numbe�)�PO.ROUTE ANO BOX NUAABER
��? _ �I h1 D�eQ--I_�r lJ f� __._ — — - ---
OTHER DESCRIPTION!lot and 8�ocic Numben.ett.) . '
.�O't" .I� 1 UW�T 4 IS�A��_�STATE, �F_CI.tARt,t1ATEiZ __------ - -
--�- ----- -- -
C�� STATE �` ZIPCOOE
CLEAQ�,VATE2- 34�30
SECTION 8 FLOOD INSURANCE RATE MAP(FIRM)INFORMATION .
Provide the following(�om the proper FIRM (See Instructions):
t.COMMUNITY NUMBER 2 �ANEI NUMBER 3.SUfFIX 4.OATE OF FIqM INDEX 5.FIRM ZONE 6.BASEO 2�OSuse depthlN
�zso 9� Oo�B D l3- �9'3� AC 1/
7. Indicate the elevation datum system used on the FIRM for Base Flood Elevatio�s(BFE): NGVD'29 ❑Other(describe on backj
�For Zones A or V,where no 8FE is provided on the FIRM, and the community has established a 8FE tor this building site.infiicate
the community's BFE:+_ ..._. .... .. �.'�:teet NGVD(or other FIFiM datum-see Section B, Item 7).
SECTI�N C BUfLDINO ELEVATION INFORMATION
•'sing the Elevation Certificate Instructions,indicate the diagram number from the diagrams found on Pages 5 and 6 that best
�escribes ihe subject building's reference level� .
2(a). FIRM Zones At-A30,AE.AH,and A(with BFE). The top of the reference level floor hom the selected diagram is at an elevation
� of�_1!_.! i�!.l�feet NGVO(or other FIRM datum-see Seciion 8, Item 7).
�, FIRM Zones VI•V30, VE,and V(with BFE). The bottom of the lowest horizontal structural member of the�eterence level(rom
the selected diagram, is at an elevation of�1—L�.�.0 feet NGVD(or other FIRM datum--see Section B, Item 7j.
�F►RM Zone A(without BFE). The floor used as the reference level from the selected diagram is �.�_'feet above._! or
below_� {check one) the highest grade adjacent ta the building.
� F1RM Zane AO. The floor used as the re(erence level from the selected diagram is ��.U teet above�� or below�(check
one)the highest grade adjaceM to the buildin�. If no flood depth number is available,is the building's lowesi fbor(reference
level)elevated in accordance with the community's tbodp�ain managemeM ordinance? [_.] Yes [� No ❑ Unknown
3. Indicate the elevation datum system used in determininQ the above reference Ievel elevations:�NGVO'29 ❑ Other(desc�e
under Comments on Page 2). (NOTE: N ihe elevation datum used in measwing the e�evations is diHerent than that used on
the fIRM (see Section B, Item 7J, then ronven the elevatbns to the datum sysfsm used on the FIRM and show the corrversion
equation under Commer►ts on Page 2.)
4. Elevation�e(erence mark used appea�s on FIRM: ❑ Yes �No (See Instructions on PaQe 4)
5.The reterence level elevation is based on: � actual oc�truction ❑ oonstruction drawings
(J1tOTE: Use ol consfruction drawings is only valid illhe bu►�dJnQ does�rof yef have the relerenue lev�el l�oor!n place, in which
case this cerNlfcate will only be val�d/or the buildJnQ durin�the ccuise v�cnnstn�ction. A post-constn�ction F�evallon Ceriilicafe
wrll be required once consnuction is comp/ete.)
8.The elevadon of the Iowest prade immediately adjacent to the buildirp is:LLI�J.U (eet NGVO(or other FIRM datum•see
Section B, Nem 7).
SECTION 0 COMMUNITY INFORMATION
. It the community oHicial responsibte for verifying buildirp elevations speCities that the reference level indicated in Section C, Item 1
is not the"lowest 800r"as defined in the communiry's floodplain management ordinance,the elevafion of the building's'Iowest
floor"as defined by the ordinance is: �`}_1�.J.0 feet NGVD(or other FIRM datum-see Sedion B,Item 7).
�Date o!the start ot construction or substantial improvement _ --
fEMA Fortn 81•31,MAY 93 REPUICES All PREV10U5 EOCIlOtJS SEE REVERSE SIDE FOR COMiNUAT10N
Apr.-22-98 03 : 17P POLARIS SURVEYING 813 449 2778 P.02
~ SEC710N E �CERTIFlCATION
This certificat�on is to be signed by a land surveyor, eng�neer.or arch�tecf who is authorized by staie or bcal law to certity elevation
m':rmation when the elevation information for Zones At-A30, AE.AH,A(with 8FE),V1-V30,VE,and V(wilh BFE)is required.
Community oHicials who are authorized by tocal�aw or ordinance to provide floodplain management in(ormation,may also sign�
certification. In the case ot Zones AO and A(without a FEMA o►community issued BFE),a bu+lding of�icial,a property owner,o;
owner's representative may also sign the certificalion.
Aefere�ce level diagrams 6, 7 and 8-Distinguishing Fealures-If the certifier is unable to cert�ty to breakaway�non-breakaway wall,
enclosure size, location ot servicing equipment,area use.wal!openings,or unfinished area Feature(s),then fist ihe Fealure(s}not
included in the certification under Comments below. The dia9ram number,Section C,ttem 1,must still be eniered.
I certily that the inJormafion in Sect,ons 8 and C on thrs cer,rficate represents my best elloRS to interp�et the data avarlable.
!understand that any false statement may be punishable by ine or imprisonment under 18 U.S. Code, Section f001.
CEflTtF1ER'S NAME IICENSE NUMBER(or Atl�:Seap
�t�'A ti' � +�7. �����.�� LS 38 a S
TITLE C�'aP;1N��AME ,
LAND SURVEYOR pOLARIS ASSOCIATES, INC. �
AOOAESS C::Y STATE ZIP
P.O. ��50 ` _ CLEARWATER FL 34b18
SIGNATURE DATE PHONE
� /2- �-9F� (813 ) 449-2775
Coples s ould ba made oi this Certlilcate tor:1)community oHiclal,2)insurnnce ag�nUCO�np�any,and 3)build(ng owner.
COMMENTS: __._ _ ___ ^__
_ � _. _ .�
a, wm+ oN v��es.
sus ��so�xr nEas.oR cauin+s
A V A A V
ZONES ZONES 20NES 2�ONES ZONES
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The Ciagrams above itlustrate the points at which the elevadons should be measured in A Zones a�d V Zones. �
Elevations for all A 2ones should be measured at the top of the reference ievel Aoor.
Elevations tor all V Iones should be measured at the bottom af t�e lowest hori=ontaJ sUUCturaf inember.
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