18445 NE 30 AVEFEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
Read the
O.M.B. No. 3067 -0077
Expires July 31, 2002
SECTION A - PROPERTY OWNER INFORMATION I For Insurance Company Use: I
BUILDINCc��ST T ADDRESS (Indudin Apt., Unit, Suite, and /or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
/X,� ,(J� 30 quenue /
CITY' 11^71'a "77 F6O Al � Q ZIP CODE
Numbers,
_ /-I2Slcyo/1 //w
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: L GPS (Type):
( or ##.##### ") UNAD 1927 1_I NAD 1983 "USGS Quad Map LI Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
1. FIP COMMUNITY NAME OMMUNITY NUMBER
B2. COUNTY NAME
B3. STATE
6�Li
n i1Go2 ra eod- OG3✓
of
OE
B4. MAP AND P EL
85. SUFFIX
6EAR RM INDEX
B7. FIRM PANEL
B8. FLOOD
B9. BASE FLOOD ELEVATION(S)
NUMBER
/ G oorl
S
DATE
?—/ ?- q'tr
EFFECTIVE/REVISED DATE
-5 -a - ¢
ZO E S)
(Zone A , use,depth of flooding)
�.0
B10. Indicate the source of th!,Elase Flood Elevation (BFE) data or base flood depth entered in B9.
I —I FIS Profile FIRM LI Community Determined I_1 Other (Describe):
611. Indicate the elevation datum used for the BFE in B9: L, -tNGVD 1929 1_1 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_J Yes 1_,+No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: 1_1Construction Drawings' 1_IBuilding Under Construction" L,4Rnished Construction
'A new Elevation Certificate Illpa 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), Al ARIA, AR/AE, AR/Al -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. Use the space provided or the Comments area of Section D or Section G, as appropriate, to ant the datum conversion.
Datum Conversion/Comments
Elevation ref6rence mark used 011n 71f Does the elevation reference mark used appear o the )FIRM? 1_f Yes LI No
f Top of bottom floor (nduding basement or /enclosure) f L ft.(m)
❑ b) Top of next higher floor 0
ft.(m)
❑ c Bottom of lowest horizontal structural member _ }
(V zones only) � ft.(m) tt o
Imo) Attached garage (top of slab) i 7 ft.(m)
❑ e) Lowest elevation of machinery and /or equipment m m \ Q
servicing the building t, �Q _ft,(m) E c i! 1
Vf� Lowest adjacent grade (LAG) t -7 O ft(m) z a 1 \�
0' g) Highest adjacent grade (HAG) *i ft. (m)
❑ h) No. of permanent openings (flood vents) within 1 ft. above adjace t grade l
Q 16?
❑ i) Total area of all permanent openings (flood vents) in C3h_ sq. in. q. cm)
U
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 an false statement a be punishable b fine orim imprisonment under 18 U.S. Code, Section 1001.
CERTIFj�R'$ NA D - q G a LICENSE NUMBER
•••�- Z >0a-60,,C-4 /O V- / / VVIYIrNY11Y 1.. YYELT• r-
SIGNAT E O V"-- DATE q TELEPHONE 13 0 dtr3` 65 Occ: 4 /
FEMA orm 81 -31, AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In theses aces, co py the corresponding information from Section A. I For Insurance Company Use:
STATE ZIP CODE
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_I 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 fora LOMA orLOMR -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 top of the bottom floor (including basement or enclosure) of the building is I I I ft.(m) LLIin.(cm) 1J above or 1J 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
I—L-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? 1_I Yes Li No LI 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
1-1 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.)
G2.1 I A community official completed Section E fora 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.
G4. PERMIT NUMBER - G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCEIOCCUPANCY
ISSUED
G7. This permit has been issued for: 1_1 New Construction 1_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
Check here if attachments
FEMA Form 81 -31, AUG 99 REPLACES ALL PREVIOUS EDITIONS