18365 NE 30 CTFEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Read the instructions on pages 1 - 7.
O.M.B. No. 3067 -0077
Expires July 31, 2002
SECTION A - PROPERTY OWNER INFORMATION 1 For Insurance Company Use: -1
BUILDING OWNER'S NAME Policy Number
BUILDING 71S MSS (InI I Apt., euite, nd /or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
CITY /�' /� / p �! STAVE ' 0 'e /Q� ZIP CODE
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
##' - ##.##" or
etc. Use Comments section if necessary.)
1J NAD 1927 IJ NAD 1983
USGS Quad Map 1_I Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
�Bt. FIP COMMUNITY NAME & COMMUNITY NUMBER
.L/ /N /Zo635
B2. COU TY NAME
�r'q A�f / - �f+DO
B3. ST
cow r
(Top of next higher floor
f- ft.(m)
a
B4. MAP AND PANEL
NUMBER
B5. UFFIX
B6. FIRM INDEX
DATE
B7. FIRM PANEL
EFFECTNE/REVISED DATE
B8. FLOOD
ZONE S)
B9. BASE FLOOD ELEVATION(S),
(Zone AO, use depth of floodir
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
I_I FIS Profile
Lt - FIRM I_J Community Determined LJ Other (Describe):
B11. Indicate the elevation datum used for the BFE in 69: 1 NGVD 1929 1_1 NAVD 1988 LJ Other (Describe): _
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?
Designation
1_1 Yes 1_1 No
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: JlConstruction Drawings* 1_1Building Under Construction` LJFinished Construction
'A new Elevation Certificate II be required when construction of the building is complete.
C2. Building Diagram Numbe � (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 430, 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
calculatio . Use he pace provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
DaturtY`+- . V 21 ConversiorU(Comments
Elevation reference mark used 049LI� Does the elevation reference mark used appear on the FIRM? J Yes J{ `
9-2) Top of bottom floor (including basement or enclosure)
8 00 ft.(m)
v
(Top of next higher floor
f- ft.(m)
a
❑ c) Bottom of lowest horizontal structural member (V zones only)
ft.(m)
S
Er 'd) Attached garage (top of slab)ft.(m)
$ q
❑ e) Lowest elevation of machinery and/or equipment
servicing the building
7t' .(0_0ft.(m)
g
9 fj Lowest adjacent grade (LAG)
(ml
z N
❑ g) Highest adjacent grade (HAG)
—ft.
_fL(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 efforts to interpret the data available.
I understand that anv false statement may bejeunishable by fine orimorisonment under 18 U.S. Code. Section 1001.
INC
IFEMA 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: J
►1419
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.
1 -1 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 E1 through E4. If the Elevation Certificate is intended for use as supporting
information for a LOMA orLOMR -F, Section C must be completed.
Et. 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 LJJ fL(m) I_Llin.(cm) Ll above or Ll below
(check one) the highest adjacent grade.
E3. For Building Diagrams 6 -B with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is
I_lJ ft.(m) LlJin.(cm) above the highest adjacent grade.
E or 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? I 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 owners 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
COMMENTS
I —I Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete
S -)ns A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below.
G, , I 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.)-
G2. 11J 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: 1J New Construction 11_1 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