18430 NE 30 AVEFEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Read
on panes 1 - 7.
O.M.B. No. 3067 -0077
Expires July 31, 2002
SECTION A - PROPERTY OWNER INFORMATION For Insurance Company Use:
BUILDING OWNERS NAME If
Bldg. No.) OR P.O.
AND BOX NO.
CITY Q "*" STATE � O�� ZIPCODE
/- d�
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
(e.g.,
( W- ##'- ##.##° or
I MAD 1927 1_1 NAD 1983
1_1 GPS (Type):
LI USGS Quad Map IJ Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
IP COMMUNITY NAME & OM�tUNITY NUMBER
/1 co1,p e� ee� -/ 06 5�
B2. COUNTY NAME
172AG1ni_ Q�c%
83. STATE
d•G✓C�
B4. MAP AND PA
NUMBER
EL
65. SUFFIX
B6. FIRM INDEX
B7. FIRM PANEL
B8. FLOOD
B9. BASE FLOOD ELEVATION(S)
2a)v —C �q
DATE
'7 �%,l ✓
EFFECTIVEREVISED DATE
ZOjIIE S)
(Zone use depth of flooding)
B10. Indicate the
urce of these Flood Elevation (BFE) data or base flood depth entered in B9.
" ria r -romie I -,t-rrttM LI Community Det fined IJ Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: 1�JGVVD 1929 1J NAVD 1988 1J Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? L1 Yes I
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION /SURVEY RFnUIRFnt
Ct. Building elevations are based on: 1_1Constructlon Drawings' 1_1 Building Under Construction" I finished Construction
'A new Elevation Certificate I be required when construction of the building is complete.
C2. 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.)
C3. Elevations - Zones Al -A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, ARM, 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
calculation. space provided or the Comments area of Section D or Section G, as appropriate, to document datum conversion.
Datum A/ i-VP Conversion//�j omment
Elevation re nonce mark used c%OU� Does the elevation referen m rk used appear on the FIR ? I Yes 1_1 No
19ra) Top of bottom floor (including basemen oar enclosure) 4- ft.(m) A
❑ b) Top of next higher floor n _ ft.(m)
I7 c)-Bottom of lowest horizontal structural member (V zones only)
d) Attached garage (top of slab) f ft.(m) m i
Q e) Lowest elevation of machinery and /or equipment
servicing the building fL(m) a ` G
�Cowest adjacent grade (LAG) p fL(m) i„ I �C7C
d�y
g) Highest adjacent grade (HAG)
❑ h) No. of permanent openings (flood vents) within 1 ft. above adja nt grade §
❑ i) Total area of all permanent openings (flood vents) in C3h sq. in. (sq. cm)
SECTION D - SURVEYOR, ENGINEERTTTOR`R ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
1 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 any false st�ent may be punishable by fine orlimprisonment under 18 U.S. Code. Section 1001.
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FEMA Dorm SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS