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18370 NE 30 AVEPROCESS# FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.S. No. 3067 -0077 FOLIO # f NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002 c.o.rt ��j ELEVATION CERTIFICATE hnportant. Read the Instructions on pages 1 - 7. Amended by MDC -DERM- OCT, 1999 SECTION A - PROPERTY OWNER INFORMATION For Insurance Company Use: BUILDING OWNER'S NAME Policy Number BUILDING TREE7 AIT , BOX O Company NAC Number /S F n Apt-, Unit , . . .. d cl � CITY STATE ,/ ZIP CODE PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) BUILDING USE (e.g., ggee9�identiai, Non - residential, Addition, Accessory,sfc. Use Comments section if necessary.) LATITUDEfLONG1TUDE (OPTIONAL.) HORIZONTAL DATLU, SOURCE: © GPS (Type): -;#' - ##.#if or ##.###tit#°) E] MAD 1927 )] NAD 1983 D USGS Quad Map ❑ Other: SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 81. FIP COMMUNITY NAME & COMMUNrrY NUMB B2. COUNTY NAME B3. S TE i �/,U /�n - 17r;/��� 64. R9AP AND P 03,101 B5. SUFFIX 1 FIRM INDEX B7. FIRM PANEL B8- FLOOD B9. BASE FLOOD R FVATION(S) NUMBER Q� TE EFFECTIVVEfREVISSED DATE ZONE(S) (Zone Ate' e depth of flooding) I20Z5G DO �y us $iO. Indicate the source of th _5_Base Rood Elevation ($FE) data or base flood depth entered in B9. RS Profile ErFIRM [] Community ❑ Other (Describe): B11. Indicate the elevation datum used for the BFE in B9: lErkGVD 1929 j3 NAVD 1988 [] Other (Dew- -e): B12. Is the bidding located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑ Yes © No Designation Date SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl- Building elevations are based on: 0 Construction Drawings* (] Buld ng Under Gorstrr(.`hon' &frushed Construction 'A new Elevation Germ will be required when construction of the budding is complete. C2. Budding Diagram Numb (Select the building diagram most similar to the budding for which this certificate is being completed - see Pages 6 and 7. I no diagram accurately represents the budding, provide a sketch or photograph.) 03. Elevations - Zones Ai -A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, ARIA, AR/AE, AR/Ai -A30, AR(AH, AR/AO Complete Hems C324 below according to the budding 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 catcu}a n�)/Use the space provided or the Comments area of Section D or Section G, as appropriate, to dor.ument the datum conversion. Datum Convers"WComnueribi Elevation reference mark used ClW o ite elevation reference mark used appear on the FIRM? [] Yes ❑ No a) Top of bottom floor (including basement or enclosure) f 8 ft(m) m O b) Top of next higher floor .Ullf. ft.(m) Cl C) Bottom of lowest horizontal structural member (V zones only) ,G`'-if fltm) au ❑ d) Attached garage (fop of slab) 1 f�� (m) E. O e) Lowest elevation of machinery andlor equipment ,p _ (l servicing the budding G O ft. m E m ` n *�1 rr' _ { ) ❑ f) Lowest adjacent grade (LAG) t �J }L(m) z' u 61 U 9) Highest adjacent grade (HAG) iL © h) No. of permanent openings (flood vents) within 1 it above adj cent grade EI 1) Total area of an permanent openings (flood vents) in C3h _sq in. (sq. cm) SECTION D - SURVEYOR ENGINEER OR ARCHftECT CERi7FICATION ihls cerbficaHon is to be signed and sealed by a land surveyor, engineer, or arch tect authorized by law to certify elevation information. 1 certify that the information in Sections A B, and C on ibis certificate rep2sents my best efforts to interpret the data available. f understand that any false statement ma be punishable by fine or imprisonme ri under 18 U.S. Code, Section 1001. CERTtFIER'SNAME �,� 17 �� �v. LICHNSENUWHTA SURVEYORS INC _ AMA -13ZU5 5 W 137TH AVZ 577 225 ADDRESS CITY �- STATE IP SIG NATU -� _ DATE �-�TELF O I�, FEMA Form 81 -31, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Uses BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number CITY STATE ZIP CODE SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenticompany, 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 E1 through E4. If Me Elevation Certificate is intended for use as supporting information for a LOMA or LOMR -F, Section C must be completed. E1. 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 tap of the bottom floor >:- eluding basement or enclosure) of the building is ;_j _I IL(m) I_`lin.(cm) j_j above or I_I below (check one) the highest adjacent grade. E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is 1_1J fL(m) I I 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? 1_1 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 INFORMATION (OPTIONAL) The local 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.) G2. Ll 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. Ll The following information (Items G4 -G9) is provided for community floodplain management purposes. G7. This permit has been issued for: 1_1 New Construction "Substantial Improvement GB. Elevation of as -built lowest floor (including basement) of the building is: _ ft.(m) Datum: 69. SFE 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 COMMENTS Check here if attachments FEMA Form 81 -31. AUG 99 REPLACES ALL PREVIOUS EDITIONS