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1412 JEFFORDS STUS. DEPARTMENT OF NOMEIAND SECURITY ELEVATION CERTIFICATE FmERAL EMERQENCY MANAtiEMENT AGENCY Naci�t Plood tmvranre Program IMPORiANT: Foilaw the lnstr[ictions on pages 2-9. SECTION A — PROPERTY INFORMATION A1. Building Owner's Name A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box � A��f I�e���rie�e� w�..�..� OMB No. 1660-0008 €xpir�tio� Date;luly �1, 20�.5 FOR INSURANCE COMPANY USE Policy Number: ��� CLEARWATER State F� ZIP Code 33756 A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) PARCEL 1429-15�6852-000-0020, LOT 2, PARKWOOp 4TH ADD, PLAT BOOV( 060, PAGE 046, PMH.LAS CpUN'fY� FLORIDA A4. Buiiding Use (e.g., Residerrtial, Non-Residerrtial, Addition, Accessory, etc.) RESIDEIVTIA� A5. Latitude/Longitude: Lat. 27�9�6 Lo�g. -82.7786 Horizontai Datum: ❑ NAD 1927 Ox NAD 1983 A6. Attach at least 2 photographs of the building 'rf the Certificate is being used to obtain flood insurance. A7. Building Diagram Number ONE-A A8. For a building with a crawlspace or enclosure(s): A9. For a buiiding with an attached garage: a) Square footage of crawlspace w enclosure(s) wA sq ft a) Square footage of attached garage 462 s ft b) No. of permanent flood openings in the crawlspace or 4 enclosure(s) within 1.0 foot above adjacent grade wA b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade NA c) Total net area of flood openings in A8.b wA sq in c) Totai net area of flood openings in A9.b wA sq in d) Engineered flood openings? ❑ Yes � No d) Engineered flood openir�s? ❑ Yes � No SECTION B— FLOOD 1NSURANCE RATE MAP (FlRM) INFORMATION 61. NFIP Number 12103C0109 2 CITY O� N�m�r Suffix 86. FlRM Index Dat H 08H 812009 62. County Name PINELLAS 67. FIRM Panel Effective/ Revised Date 05/17l2005 Zone(s) AE � 63. Stete FL Base Flood Elevation(s) (Zone AO, use base fload depth) 28.0 FT B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth errtered in item B9: ❑ FlS Profile � FIRM ❑ Community Determined ❑ Other/Source: Bii. indicate elevation datum used for BFE in Item 69: � NGVD 1929 � NAVD 1988 ❑ Qther/Source: 612. Is the building located in a Coastal Barrier Resources System (CBRSj area or Otherwise Protected Area (OPA)? ❑ Yes � No Designation Date: / / ❑ CBRS ❑ OPA SECTION C— BUILDIN(i ELEVATION INFORMATION {SURVEY REQUIRED) Ci. Building elevations ar� based on: �Construction Drawings* ❑$uikling Under Construction* � Finished ConsVuction *A new Elevation Certificate wiil 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, AR/AO. Complete ftems C2.a-h below according to the building diagram specified in Item A7. in Puerto Rico ony, enter meters. Benchmark Utifized: G� Vertical Datum- NAVD �988 I�dicate elevation datum used for the elevations in items a) through h) bebw. ❑ NGVD 1929 � NAVD 1988 ❑ Other/Source: Datum used fw buiiding elevations must be the same as that used for the BFF_ a) Top of bottom floor (including basement, crawispace, or enclosure floor) b) Top of the ne�ct_higher floor c) Bottom of the lowest horizorrtal sWCtural member (V Zones only) d) Attached garage (top of siab) e) Lowest elevation of machinery or equipmerrt servicing the building (Desc�ibe type of equipment and lacation in Commerrts) f) Lowest adjacent (finished) grade next to building (LAG) g) Highest adjaceM (finished) grade next to buildir� (HAG) h) Lowest adjacerrt grade at lowest elevation of deck or stairs, including structural support Check the measuremerrt used. 28.87 � feet ❑ meters N!A � teet D meters N/A � f2et ❑ IT1ete�s 28.0 � feet ❑ meters 28.6 � i� ❑ �ers 28�0 � feet ❑ meters 28A � feet ❑ meters 28�0 � feet ❑ meters SECTION D— SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION T'his certification is to be signed and sealed by a land surv�yor, engineer, or architect authorized W law to c�rtifv e�levari�n oCC rCVCrse sioe ror wntinuauon. Repiaces all previous editions. ELEVATION CERTIFlCATE, page 2 �mnmrwm: m mese sPacas. coPY the correspo�xling tnformation from Secfion A. Building Street Add�ess (including Apt., Unit, Suite, and/or Bldg. No.j or P.O. Route and Box No. 1412 JEFFORDS STREET City State ZIP Code CLEARWATER _ FL 33756 Policy Numbet: Company NAIC Number: SECTION D- SURVEYOR, ENGINEER, OR ARCHITECT CERTIFlCATION (CONTINUED) Copy both sides of this Etevation Certificate for (1) community official, (2) insurance agent/comparry, and (3) building owner. Comments �F EQUIPMEIYT IS USTED ON PRIOR PAGE IS BASE OF AIR CONDITIONER UNIT THIS CERTIFICATE IS NOT TO BE USEO FOR CONSTRUCTION OR DESIGN, IS FOR FLOOp INSURANCE USE ONLY Signature Date 01 /1 42 01 4 USE 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 ony, enter meters. E1. Provide elevation information for the followi�g and check the appropriate boxes to show whether the elevation is aba�e 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 � abwe or ❑ below the HAG. b) Top of bottom floor (inciuding basemeM, crawispace, or encbsure) is . � feet ❑ meters � above or ❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A ftems 8 and/or 9(see pages 8-9 of Instructions), the neM higher floor (elevation C2.b in the diagrams) of the buiiding is �. A � feet ❑ meters � abave or ❑ below the HAG. E3. Attached garage (top of slabj is . � feet ❑ meters � abwe or ❑ bebw the HAG. E4. Top of platform of machinery and/or equipment servicing the building is . � feet ❑ meters � abwe or ❑ bebw the HAG. E5. Zone AO only If no flood depth number is available, is the top of the bottom floor �levated in accordance with the communitys floodplain management ordinance? � Yes ❑ No ❑ Unknown. The Ixai officia� must certify this informaCwn in Section G. SECTION F- PROPERTY OWNER (OR OWNER'S REPRESENTATIYE) CER7IFlCATION The property owner or owner's authorized represerrtative who completes Sections A, B, and E for Zone A(wrthout a FEMA,-issued or community-issued BFEj or Zone AO must sign here. The statements in Sections A, B, and E are correct to the best of my knowledge. Property Owner os (�y�er'S AuthO�RCd R6DfBSEntative's Name � __ _ C� Address Signature Comments Gt, s- City Date �G` ZIP Code 3 T 7 G�-- Telephone 7 Z-1 � f- 3 7� L �j Q" � 6,/���i� ❑ Check here if attachmerrts. SECTION G - COMMUNITY-INFORMAT-IaN-(�PTIONA�} The tocal official who is eutho�ized by law or ordinance to administer the community's floodplain management orclinanCe can complete Sections A, B, C(or E), and G of this Elevation Certificate. Complete the applicable item(s) and stgn 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 crommunity official compieted Section E for a building located in Zone A(without a FEMA-issued or commun'rty-issued BFE) w Zone AO. G3• ❑ The foilowing iniormation (Items G4-G9) is provided for community floodplain management purposes. G4. Perrnit Number G5. Date Permit Issued G6. Date Certificate Of Compiiance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑ SubstaMial Improvement G8. Elevatian of as-built lowest floor (including basement) of the building: . ❑ feet ❑ meters Datum G9. BFE or (in Zone AO) depth of flooding at the building site: . ❑ feet ❑ meters Datum G10.Communiry's design flood elevation: . ❑ feet ❑ meters Datum Lacal Otficial's Name Community Name Signature Comments Title CLEARWATER CiTY OF Telephone Date ❑ Check here if attachments.