1451 RIDGELANE RD. .�
U.S, DEPARTMENT OF HOMELAND BECURITY
FBDERAL EMEROENGY MANAOEMENTAO�NCY
N6Nonad x7ood li�siirance Prograni
�I�E�/ATION CERTIFICA�'E
Important: Read the instructions on pages 1=8.
SECTION A = PROPERTY INFORMATION
OMB No. 1680-0008 �
Expiration Date: Juiy 31, 2015
__
. 1�E.Rt��( \IIGKI E. c QM
A2. Bu(Idin Street ddresa i(�r cluding Apt,, Unit, Suite, and/or Bldg. No.) or 1'.O. Route and Box No. �: �
��1 �t���L�rJ� (�oAr�J ,�
A4. Building Use (e,g., Reeldentiel, N n-Residendel Addiflon, Aaoeesor , eto.) i� E� ���. 1~� ( �,,
A5. Latitude/Longitude: Lat: �� � r . tij�� Lon . 2p �
� -r�J--�-'-�4- Horizontal Detum: ❑ NAD 1927 NAD 1983
A6, Attach at least 2 photopraphs o the building if the Certlfivate le beino ueed td obtain fiood Ineurance:
A7. Building Diegram Number • :
A8. �'or a building wtth a cPawlspace or enalosure s • �
O N A9. For a building with an attaohed garage: �
a) Square footage of crewt� eae ar enclosure(s) � aq ft a) Square footage of etteohed ga[ape • �� � eq �
b) Nurriber of perman�nt �i���'openinga in the crawiepace b) Number of permanent tlood'openlnps in.the ttached garaee
or enclosure(s) within 1�"��df`ebove ed acenf Fade
,, � 8 withln 1 A.Faot above adjacent prade.
cj Total net area of flaod ob��5lYiga In AB.b rq in o) . TOtai net area of tiood openinge In Ae.b �, eq fn
d) Englneered flood openings'7 ❑ Yes ❑ No d) Englneered,llood openings2 (] Yea .[]. No
3ECTION 8- F1.00p IN8URANG� RATk MAR (FIRM INFORMATION
S1. NFIP Communit Name & Communli �um�r B2. Cdunty Name ���� B3. State �
' G��� R v�/Y,4`t+� �R. 5,� u�,,4:� a
- 8�4. Map/Panel Number 65. SuiFix B8. FIRMind�x Date B7. FIftM Panel B0. Flood 89. Base Flood Elevation(s) (Zone
(�� p7) � �! p�7 �.:� 5/ �, /� Effect�e/Re�vlsed�Date Zpn�e(s) . AO;'se base flood depth)
/ ; � ,
; B10. Indicate the sowrce o(the �ase Flood Elevatlon (�FE) data or tiase tlood depfh e ered In Item 68>
❑ FIS Proflle ' Gd�FIRM ❑ Community Determined ❑ OthedSOUrce: . ,
811. Indicate elevatlon datum used for eF� In Item 89: [] NOVD 1929 �NAVD 1968 ❑ Other/Source: �
B12, la the building located in a Coastal Barrier Resourcea System (OBRS) area�th.erwise Protected Area (OPA)7 Cj Yes No
Deeignation Date: C7 C$R5 . � OPA
8ECTION C - BUILDINa ELEVA
J IN�ORMATION I
, ---
C1. Building elevations are based on: ❑ Conatruction Qrawln8s' �ullding Under Canetruotion" j] Flniehed Constructlon
"A new Elevatlon CartiFicate wiil be required when oonstfuctlon o1 the building Is complete.
C2. Elevations -�onea A1-A3Q, AE, AH, A(witli 9FE), VE, V1-V30, V(with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AW, AR/A0. Compiete Items C2.a-h
below accvrding to th buildin dlagram epeclfled in Item A7. In Puertb Rico only, enter metera.
Benchmark Utllized: � ��a'��,� ��� Q�� VeKical batum: �� � 5
indiaate elevatlon deEum uaed for the elevationa in. items e) through hj belpw. ❑ NOVD 19�AVQ 1888 C1 QthedSource:
Datum used for build(ng elevatipn$ must be the same as that used for'the �FE. .
e) Top of botto�n floor (Including besement, crawlspece, or encivsure tloor) �. � �eet p meters
b) Top of the next hi8her tloor N A ❑(eet � 0 metare.
c) Bottom of the lowest horizontal structural member (V Zones only) �� [,�), �feek [I meters
� d) Attached gerage (top of siab) �. ( �reet Cl meters
e) Lowest elevation of machinery or equipment e�rvicing the building �.�, � [H'�et ❑ meters
(Descriqe type of �quipm�nt and Iocation in Commenta)
� Lowest adjacent (flNshed) grade next to bullding (LAO) —�I 9 [�eet ❑ meters
g) Niglteat adjacent (flniahed) grade next to bulidinp (HAa) �,�,�_ �feet I] meters ,
h) Lowest adJaoent grade at lowest elevation ot deck or atairs, includin8 structural. suppott �IA �] feet ❑ meters
3ECTION D= BURVEYOR, �NOIN�ER, OR ARCHIT�C7 C�R7IFICATION
Thfs cerfiflcatfbn is to be signed and sealed by e land surveyor, englneer, or architect authorfzed by law to certify eievation �_,, ,
informatlon. l cert!!y thaf the informatlon on fhls Certlt%afe reprasenfs my besf efPorts to lnferp►'et fNe data avaUsble. ,". `'"' �"�'�
! un erstand thaf any false staferrtenf may be punlsltable by flne orlmprlsonmenf under 19 U.S. Code; Secflon 1001. - .
Check here ff commenta are provided on baok of form. Were Iatitude and longitude tn 3e�tlon A provfded by a : f �a�„"'Y,�M"�� `
�Check here If attachments. Iicensed land surveyor7 C�Yes ❑ No �.� °: ��r,�� {.
Certifier`s Name LARRY L. EVANS License Number PL8 # 2937 4- y� �'��'
Tltle LAND SURVEYOR Company Nam� EVAN3 LAND SURVEYINO, INC. � � _
Address 1460 BELTRE�S 5�' STE: 8 Cfty DUNEDIN, 8tete FL ZIP Gode 34698 ��s
Date � � ..�p�.,. _ �j ( ,�-'.� Telephone (727) 7343821
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RMI�.�VA I IUN. C:�K 1 IPI�:A I�� �8g@ '�" �` '
` I�ORTANt: ln these spac�s, copy the corresponding informatiori from Section A. " �'
Bultding treet Addreas Qncluding Ap ., Unit, Sulte, and/or Bldg. No,) or P.O. R�ute ahd Box No. �. '�j �" • ` "�
� r'�' ( }�' � j� �,i �, �,,,� � �,, p , �. - .
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LL'� ���.T�-�- State � � ZIP. Code 7�3�.�'is
SECTION D- 8URV�YDR, ENOINEEFt, OR AREHITEGT CERTIFICATION (GONTINU�Dj
Copy both sidea of thla.�levetlon Ceni(icate for (1) Community offlclal, (2) Insurancs agenVcompany, and (3) buildfng owner.
commenta G .L �'� � ( `,' �,�,,J �' 1CC'�.-(,�� O {� f�lG CAh'��R� �5 d b►J �(� aUN D �.E�/�L. _"�'/°�s17,
G 2, c� �� ��0 i'i o1� 0 7'�f�-, � Tl � f
,� R � 1�4P��C-� I5 Ir-1 � �vG�,,� Of l��-tr.t� �-NG�OS�..�i
�o (� L;► v � r.� G- /�K�,,q .
' Signature
� Date �'
; -0�-���.
i 3ECTION E B L IN ELEVATION INFORMATION (8URV�Y NOT R�qUIR�Dj FOR �171VE AO ANQ ZON� A(WI7HUU B��) .
"
; For Zones A0 and A(without BFE); complete Items E1-�5. If the Certiflcate fa Intended to suppart a I.OMA or LOMR-F requesf, camplete Sectiona A, B,
and C. For Items E1-�4, use natutal grade, if avallable: Check the measurement uaed. In Puerto Rico only, ent�r meters.
' E1. Provfd� elevation InCormation for the following and check the appropriate bvxee to ahow whether the elevaRlon Ia above o� beiow the highe�t adJacent
grade (HAO) and the lowest ad�a�enf grede (LAG).
a) Top of bottotn floor (inciuding basement, orawlapace, nr encloaure) is ❑ feet ❑ meters [j above nr [I below the HAO.
b) Top of bottom floor (Includirig besement, crawlepace, or enclosure) Is . I] feet ❑ mete�s �J above or CJ below the LAG.
[2. For 8ullding Dlagrama 6-9 witH permanent tlood openinge provided in SecQon A Items 8�ndlor 9(se_e,.pagea e-9 of lnstructlons), the next higher floo�
(elevation C2.b fn the diagrams) of the bufiding la .� ❑ feet ❑ mete�s ❑ above or [) below the HAO.
E3. Attached garage (top of slab) Is [' feet ❑ metera ❑ above or ❑ below lhe HAQ.
E4. Top of plattorm of machinery and/or equipment aerv(cing the building ls ❑ feQt ❑ metera ❑ above or � belpw, the HAG. �
E5: Zone AO only: if no flood depth number Is avallable, is lhe top of the bottom floor elevated in accordanoe wlth the community's floodplaln manegement '
:
ordinance? [� Yes [J No ❑ Unknown. The locel offlcial muat ce�tify thls Information in Seotlon Q.
..,.
SECTION F-�'�t�h�RTY OWNER �OR bWNER'S REPRESENTATIVE) CERTIFICATION `
The property owner or vwner's autiiorized representadve who obmpletes 5ectlone A, B, end E(or Zone A(wfthout a FEMA-issued or.community-Iseued BFE)
or Zone AO must aign here. The statementa In Sections A, B, and E are correct-�e-the best of my knowledge.
Property Owner's or Owner's Authorized Repreaent�tive's Name
Addres� City State ZIF' Code
Signature � bate 7elephone
Comments.
- CI Cheok here if attachments.
"
3ECTION Ci — COMMUNI,TY INFORMATIQN (QPTIONALi
1;h� local offialal who is authorized by law or ordinance to administer the commt�nfty's floodplain mana�ement ordlnance can complete SectionB A, B;, C(or E), and o
o.f this Elevation Certificate. Complete ihe appilcebleJtem(aj and elgn below. Cbeok the mBasu��ment uaed In Iteme G8=410..In Puerto Rlco only, enter meters. _
�1. ❑ The in(ormatlon In 5ectlon C was taken fror►i other documentatlon that has been sipned and aealed by a Ilcenaed surveyor, engi�eer; or architect who
fs suthorized by law to cerNfy elevation informatlon. Qndicate fhe eource and date ol the elevaUon data in the Commenh� area below.)
t32. ❑ A communfty olflcial completed 3ectlon E for a buildlnp looated In Zone A(without a FEMA-Isaued or communtty-isaued BFE) or �one AO.
C,3, ❑ The followinp Intormation ptems G4-G10) la provided for communiry floodplain management purpnses:
G4. Permit Number 05. D�te Permit Iseued Ge. Date Cenificate Of Compilance/.Occupancy Issued
G7. Thls permit has been issued for: ❑ New Constructlon [7 Subatan8al Improyement
G8. Elevatlon ot as-bulit Iowest floor (inciuding basement) af the bullding: Q feet ❑ meters Datum
G9. BFE or (In Zone AO) depth of flvodfng at lhe bulld(ng elte; ❑(eet [1 metera Datum
C�10. Community'e design flood 8levatlon: ❑ feet C] meters Datum
Loaal pfficial's Name „_ 71t1e
�Community Name Telephone
Signature
Comments
Dafe
�[1 Check �je I( attachments.
__ . __
. •
ELEVATION CERTIFICATE, page 3 guiiding Photograph�
See Instructions for Item A6.
IMPORTANT: In these spaces, copy the corresponding informatlon from Section A. �OR INSUFtANCE COMPANY Us�
Buildi g Street Address (includfng Apt., Unit Suite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number`.
_� i �����.�� a��o
City �L ��� A���` State t ZIP Code �� Company NAIC Num6er:
��t / — � �
If using the Elevation Certificate to obtain NFIP flood insurance, a�x at least 2 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." When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as�
indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page.
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pLANNING & DEVELOPMENo DEPT
1451 RIDGELANE RD
gCP2014-12413
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CROM,PERRY
Zoning: Low Medium Density Re Atlas #: 252A
L _ _
U.S: pEPARTMENT QF NOMELANU SECURITY
FEDBRAL EMER(iENGY MANAQEMENT AOLNCY
NaHanal x7ood Insurance Prograni
ne �R �
A2. euiiding Street dd�e:
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-- city C L�.,'� R w,
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E�EVATION CEI�TIFICAtE
Important: Read the Instructions on pages 1-9
3ECTION A = PROPERTY INFORMATION
�- VIG�.� E c�oM _
tit, Su(te, and/or Bldg. No.) ar P.O. Route and Box No.
�a�4 � _
s��a�e ziP c d
OMB No. 1660-0008 .
, Expiration Date: July 31, 2015
�� ° 8 33 � 55
�
lumbers, Tax Parce Nu ber, L�gal Deacrlption, etc.)
- 000� c�f3D�
A4. Building Uae (e.g., Resldentl p, Non� Rasidentlal� Additlon, Aaceeeor , eta.)
A5. latitude/Longitude: Lat: �-__� 5� ?j8 ,�j Long. Z� �
A6. Attach at least 2 photograph o the building If the Certlflaate le beln0 u d
; A7: Bufldtng Dfagram Number
` A 8. �or a bu l i d ing with a ctawi9pace or encloeure(s):
a) 3quare footage of crawl� aae or encloaure(a) N� erq ft
b) Nuniber ot permanent ����'openings In the crawlepace
or enclosure(s) within 1:� ��Sbt`above adjacenf prade
c) Totei net area of flood o�i��i1�`g9 In AB.b �q ��
d) Enpineered flood openin8s? ❑ Yea ❑ No
�----- �^
81. NFIP Communit Name & Communfty Number
G�.�/�Rv�i4i�R / IZS�o�
msUwqNG�
B2. C�unty Name 83. State �
�1 N�.LL�� I ,
- B4. Map/Panei Number B5. SufBx BB..FIRM Ind�x Date
87 FIF2M P I
r�ES�a��r � �,
�� Hor(zontal Datum: ❑ NAD 1927 CJAD 1983
obta(� fl6od Ineurance: `
A9. For a building wlth an attached garage: • �
a) Square footage of attaohed gaCape 2 0 2- Sq �
b) Number of permanent tload'openinga In,the ttaahed paraoe
withfn 1.O.foot above adJ�cent grade.
o) Total net aree of flood openlnpe in AB.b �� sp �n
d) Engtneered;flood openinga2 (� .Yes . � No
�TE MAP /FIRMI IN�nonnn�r�r,�� .
, ��- l o�j C 0 107 � • ane B8. Flood 89. Ba�e Flood Elevatfon e Zone
5/ � �/,� Effective/Revised Date ��(9). AO; use base �ood d`pth).
: 870. Indicate the sowrce of the Baee Flood Elevatlon (�FE) data or baee flood d�epth�e� ered In Item 68.
[] FIS Profile CC�FIRM _ '
811. Indicate elevatlon datum used for BFE In�lt mOBB• u[]yNOVD 1 g28 ,�_., /OtherlSOU�ce: _..
812. Is the build(ng located in a Coeatal Barrler Resourcea 8yetem CBRS) area o� ONherwiae Protect�ead praa (ppp�?.
Deaignadon Date:
� C�iRB . ❑ OPA
3ECTION C— gU1LDINa ELLVA IUN INFORMATION 3U
(� Yes Ly No
C1. Buliding elevatfons are besed on: � �. Ru�Y REQUIRED) . �""�
[] Conetruction Drawinga , ❑ �ullding Under Conetruction"
°A new Eievatlo�l Certlficate will be required when constructfon of the quilding Is oompiete. Finiahed Construction .
C2. Elevationa —�ones A1-A3p, AE, AH, A(wfth BFE), VE, Vt—V30, V(with BFE), AR, AR/A, AR/AE, AR/A1—A30, AR/AH, AR/AO. Gomplete ftems C2.a—h
below according to th buildin dfagram apecifled in Item A7. In Puertb Rico only, enter metera.
B�nchmark uunzed: �.IGI-{�� ►�I D D
Vertical Detum: , i, I �j
indicate Qlevatfon datuht uaed for the elevatlona in Iteme a) through hj belpw, ❑ NOVD 1829 NAVD:1988 O ptheNBource:
Da(um uaed for buliding elevatipn� must be lhe same aa thet uped foi'the BFE.
a) Top of bottotn Floor (including besement, crawlepace, or encloaure iloor) �(�, �heck the measuremenf uaed.
b) Top of the next hipher floor N '� Cl�'�et [] meterg
c) Bottom of theloweat hotixontal structural meinber (V Zones only) �� ��est � �►natera. ,
� d) Attached parage (top oCafabj I� f�ek (] meters
e) Lowest elevetion of inechinery or equipment aervlcl�g the building �� q �e� C� meters
(Desc�ilie type of equipm�nt and location in Comments) ''—f—� CI meters
� Loweat adJecent (finished) grade next to buildins (LAO) I, G� ,_,,�
e) Highest ad)ecent (8niahed) grade next to building (HAQ) �►eet .❑ meters
h) Lowest adJaaent grede at Ibwest elevatton o( deck or ataire, inciuding structutal eupport ���— �eet_ [] meterza ,
/A ❑ feet ❑ metere
3ECTION D= BURVEYOR, �NOIN�ER, UR ARCHIT�CT C�RTIFICATION
Th(s certificatlon is to be si8ned and sealed by a land surveyor, englneer, or architect authoriaed by law to certify elevation '
Informatfon. l cerflly fhai the Jn�'ormaflon on fhls Ce�flBcafe represenfs my besf efforfs lo lnterpret the deta avallable.-� �:���; _' � f
! un isfand thet any false statement may be punlsl�sble by Ane orlmpNsonment under 18 U.S. Code; SecHon 1001, ��."'� �"�, +�
�{�i�`�!
,-.�, /Check here it comments are provided on beck oi /orm. Were latitude and ivnpitude in 3e� tion A provided by a w:`�` � � �� `
LL� Check here (f attachments. Ilcensed (and surveyor9 ►�Yes ❑ No : ; �- � �
Certifler's Name LARRY L. EVANS �'r "��� ��.
Ucense Numder PLS # 2837 ~' "�
<:� .���`�a
Tltie LAND SURVEYOR Company Name EVaNB LAND SURVEYINO, ING. " �b `�������' '�
Addresa 1460 BELTR �
5TE:8 City DUNEDIN,
Date. 05_ �
State FL ZIP Gode 34898
_ Zp � � Tetephone (727) 7343821
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I.IUN.4�K.1 It�IC:A 1 t, �agB i!
TAN7s Iri #ttese spac�s, copy the
�treet Addresa (inciuding Ap ., Unit, Sy
'6J � �' 1 � �s � �.,,� � � Fe
:orresponding Information froiin 8ectlon A.
e, and/or Bldg. No.) or P.O.Route and Box No.
q �.1s�.
� 1
CitY � State ['� � ZIP. Code Z,�J� �i� � ' 4 �4' � '� I
�L:��i �1Pk-C�� �r �_ ,;
3ECTION D- SURVEYOR, EN(31NEEf2, OFt A►RENITECT CERTIFICATION (GONTINt1�Dj �
Copy both eid�a of thia �IavaOon Certi(Icate for (1) Community afticlal, (2) insurahce agent/company, and (3) bufiding owne�.
� comments. G Z. , � � ,l.j .��► ��C,�T''�.f�l,D {� /�-lG C.��M�R� 5� d C� bnl �(� aUtil D !-rE�/�L _�i°�D,
c 2, d)'� ,� �oR°rio� o� 7't��- c�� ��� N�� 1��.�� ����. ��7 0�`.7Z�� �.i v���C-r
/���P��, q.�� �'"N� ,�+--oo.(Z ��.�8 F#/�S �7�,E.�.► iZ�-���-� �" TO M-�4TG+� ,
Signature Date
� p� ��_�,��.
;
j 3EGTIO.N E B L IN �L�VATION INFQRMATION (SURVEX NOT REqUIR�D) FOR ZONE AO ANL1 ZON� A(W17HOU�' BF�) .
; For ZoneB AO and A(wllhout 8FE); complete Iteme Ei—E6. If the Certiflaate la Jntend�d to eupport a LOMA or LOMR-F request, compiete Sections A, B,
8nd C. For. Items E1—�4, uee natu�al grede, li available: Cheok the measurentent used. In Puerto Ricd only, ent+�r meters:
' E1. Provfda etevation InCormatlon for the following and check the appropriat� hoxee tv shovir whether the elevaRlon Is above o�.below the hlgheat ad)acent
grade (HA�) and the lowest adJa�ent grade (LAG).
a) Top of bottoin (loor (Including basement, orawlspace, or enciosure) Is O feet ❑ meters CI above or O b�low.the HA4.
b) Top of botiom flobr (includirtg baeement, crawlepace, or enatosure) is . � feat � meters I� above ar Cj below the LAG.
[2. For Rullding Dla�rema 6—g wllli permanent flood openinea provided In 6ectlon A Items 8�ndlor 9(se�e,,papes e—a of Inetructiona), the next higher floo�
(elevation C2.b in the dlagrama) o( the bulldinp is ❑ fee.t ❑ mete� ❑ above or U below the HAG.
E3_ Atteched garape (top ot slab) Is . ❑ Eeet ❑ meters I� above or ❑ below the HAo. ,
E4. Top oF pletform. of machinery and/or equipment servlcing the building is . f] feet Ci metsra O abava or �1 beivw. the HAG,
E5. Zone AO only: Ii no flood depth number Is availabls, Is the top of the boltom floor elevated in accardanoe with the communfty's tloodplain management '
ordinance? C�1 Yea ❑ No ❑ Unknown. The locel otficlal must certity thls Information In SeaUan Q.
� S@GTION F-- F'�t01'�RTY OWN�R �OR OWNLR'S REPREBENTATIVE} CERTIFICATION '-
� The properly owner or owner's auttiorized represent�tive who completes Sectlona A, B, and E(or Zone A(wtthout a FEMA-isaued or,cammuntty-ieeued BFE)
or Zone A� must ei�n here. The atatemente in Sectlons A, B, and E are correct to the best of my knowledge.
Property Owner's or Owner's Authorized Repreaentative's Name
_ Clty 5tate ZIP Code
Addreas
_ bate Tetephone
5lgnature �
Comments
� �
� �j� �heck hera if attachments.
' 3ECTION (3 — COMMUN�'fY INFORMATIQN (Q.PTIQNAL)
1;ha local offialal who Is authorited by law or ordinence to edministern below. Cheok the meas�urem nt used In Itemsa08=O10cin Puerto Rico only,�enter �met rgand O
o,( this Elevaklon Certiflcate. Camplete ihe appllcAbleltem(s) and sig
�� .❑ The (nformatlon.law totoerlif elevat on In�o mat on a(In cate the sou ceeand�d tejot the eleyation dat� (nithe Com ents afea bielow.) r arohiteat who
fs authorized by Y
(32, ❑ A community offlclai completed Sectian E for a bWldln� looated In Zone A(without a FEMA-Isaued or community-Isaued BFE) or 2one AO.
(33, ❑ The followins informatlon (Itema G�4—d10) is provided for oommunity floodplain meneeement purpn�es=
d5. DBte Permit laeued C38. Date Celtiflcate Of. ComPliancelOccupancy Isaued
G4. Pennit Number .
C37. Thia permit h�e been leeued for: Cl New Constructlon ❑ 5ubatantlal Improvement
[] feet
Q8. Elevation of as-built Iowest floot (Including basement) af the buliding: ��e�t
C�9. BFE or (In Zone Aq) deplh o1 flooding at the buildfng elte: p feet
C�i10. Community's de�ign flood �levatlon:
Looal Oflicial's Name
Community Name
Slgnature
Com
Title
Telephone
Date
❑ meters
p metere.
(] meters
Datum
patum
Datum -
�[� �heck here If atta�hments.
, �
�EL.EVATION CERTIFI�ATE, page 3 guilding Phoiograph�
See Instruc;tions for item A6:
IMPQRTANT: in these spaces, copy tlie correspo�nding (nformation from Secffon A. � '� `� ' ` �" � ��'�` � ��+ „` � ``� �'` ' � ��
� ��f�t ��'"�U�l�f��� �'�(��l�f�Y �1��
5t�,! I!Q df1�FlI1� i�t rr+Sr � I r
Building Street Adtlress pncluding Apt., Unit, Suite, and/or Bldg, No.) or P.O. Route ahd Box No,
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y
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Clt ������� r ���i� ` r�i�t n� �� '� � �! ra �,
� �-'I— fZV1�r (_(� S4ate ZIP Code �`�����N I`�'� (�17 b�Y'� � ! � `��
'� '�T �- 33�5� ,,���,���, �,� ��,��� ,,;�,� �, ��t��
� i ai��.i ,.,,,,rr�� �sT1�> °�d°x,{i� �i r,.m�tia" rt�`t`�'r
If using the Elevation Certificate to obtafn NFIP flood fnsurance, ,affix at le2st 2 bu(Iding photographs below according to the instructions
for Item A6: Identify all photographs with date taken; "Front Vie�v" and "Rear View"; and, if required, "Right Side View" and "Left Side
View." When applicable, photographs must show the foundatiim with representative examples of the fiood openings or vents, as
indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page.
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