18355 NE 30 CTFEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Read the instructions on Paaes 1 - 7.
O.M.B. No. 3067 -0077
Expires July 31, 2002
SECTION A - PROPERTY OWNER INFORMATION I For Insurance Company Use:
BUILDING ST T ADDSS (Including Apt., Unit, Suite, a dlor Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
/ rV ti -3
CITY �.4l STAG O l„ 11C�4 ZIP CODE
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
BUILDING USE (e.g., Residential on- residenI3(, Addition, Accessppry, etc. Use Comments section if necessary.)
_ �l=i
LATITUDE /LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: L1 GPS (Type):
or ##.;p#p# # °) I_� NAD 1927 1_I NAD 1983 LI USGS Quad Map I_I Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. 14FIP COMMUNITY NAME & COMMUNITY NUMBER
62, COUNTY NAME
B3. S7
B4. MAP AND PANEL
B5. UFFIX
B8. FIRM INDEX
B7. FIRM PANEL
B8. FLOOD
B9. BASE FLOOD ELEVATION( —,
NUMBER
/ZOZtjGfXJB
DATE
DATE
EFFECTIVE/REVISED DATE
3 -62-
ZONE S)
(Zone AO, use depth of flooding)
Q.� '
bl U. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
1_I FIS Profile (_t'I ARM 1_J Community Determined I I Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: 1 GVD 1929 1_J NAVD 1988 1_1 Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I -I Yes LI No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LlConstruction Drawings' 17IBuilding Under Construction' 1_1 Finished Construction
'A new Elevation Certificateyilll be required when construction of the building is complete.
C2. Building Diagram Numbero_ (Select the building diagram most similar to the building for which this certificate is being completed - see
pages 6 and 7. If no dia ram accurately represents the building, provide a sketch or photograph.)
C3. Elevations — Zones Al -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 Items C3a -i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from
the datum used for the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion
calculat`io�. Use he space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversi
DaturcY` , Use
Conversio[L/Comments
Elevation reference mark used 049 jy Does the elevation reference mark used appear on the FIRM? I_I Yes I_I No
Q-a) Top of bottom floor (including basement '`or enclosure) e ft.(m)
M-'6)—Top of next higher floor 'Z ft,(m) 9
❑ c) Bottom of lowest horizontal structural member (V zones only) ft.(m) ii
t d Attached garage (top of slab) 7' Jim
U e) Lowest elevation of machinery and /or equipment w a
�
servicing the building 00 ft.(m) .8
y,/
lip Lowest adjacent grade (LAG) _ ft.(m) v y
❑ g) Highest adjacent grade (HAG) _ ft.(m)
❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade
❑ i) Total area of all permanent openings (flood vents) in C3h sq. in. (sq. cm)
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
I certify that the information in Sections A, B, and C on this certificate represents my best afforts to interpret the data available.
/ understand that any false statement may be,eunishable by fine or imprisonment under 18 U.S. Code. Section 1001.
132D5 S W ��a�u TVH$ INC
O n G—✓ —G.—L5' ri /ci
FEMA Form 81 -31, AUG 99 1 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In these spaces, copy the corresponding information from Section A. I For Insurance Company Use:
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SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)
For Zone AO and Zone A (without BFE), complete Items Et through E4. I1 the Elevation Certificate is intended for use as supporting
information for a LOMA or LOMR -F, Section C must be completed.
El. Building Diagram Number _ (Select the building diagram most similar to the building for which this certificate is being completed –
see pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.)
E2. The top of the bottom floor (including basement or enclosure) of the building is LI -1 ft.(m) LLlin.(cm) Ll above or IJ below
(check one) the highest adjacent grade.
=or Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is
1 -1 -1 ft.(m) 1_1_lin.(cm) above the highest adjacent grade.
E4. For 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? Ll Yes 1_1 No 1_1 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.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
Check here if attachments
SECTION G - COMMUNITY
T .acal official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below.
G1. 1 -1 The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor,
engineer, or architect who is authorized by state or local law to certify elevation information. (Indicate the source and date of the
elevation data in the Comments area below.)t
G2. 1 -1 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. 1_1 The following information (Items G4 -G9) is provided for community floodplain management purposes.
G7. This permit has been issued for: Ll New Construction 1J Substantial Improvement
G8. Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m) Datum:
G9. BFE or (in Zone AO) depth of flooding at the building site is: _ ft.(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
Check here if attachments
FEMA Form 81 -31, AUG 99 REPLACES ALL PREVIOUS EDITIONS