18455 NE 30 AVEFEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
O.M.B. No. 3067 -0077
Expires July 31, 2002
Important: Read the instructions on pages 1 - 7. - Z
SECTION A - PROPERTY OWNER INFORMATION For insurance Company Uae:
BUILDING TR E ADDRESS (Inc din Apt., Unit, Suite, and /or Bldg. No.) OR P.O. ROUTE AND BOX NO. I Company NAIC Number I
/� �� .3 d quena�
CITY �.•_ - STATE /'-/ / ZIP CODE
etc.
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: 1_I GPS (Type):
( ##° - ##' - ##.it#° or ##.#k### °) Ll NAD 1927 Ll NAD 1983 1_1 USGS Quad Map Ll Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
61. NFIP COMMUNITY NAME COMMUNITY NUMBER
B2. COUNTY NAME /
83. STATE�fY/
u�/� Co2 ora mod- OG3�
�r'9m /'-
MAP AND PANEL
B5. SUFFIX
B6. FIRM INDEX
B7. FIRM PANEL
B8. FLOOD
B9. BASE FLOOD ELEVATION(S)
NUMBER
L
J
DATE
EFFECTIVE/REVISED DATE
ZONE(S)
(Zone AO, use depth of flooding)
OaB4.
a ,r c o01V
7 -1,7-
3 a-
/19E
00 a
B10. Indicate the source of the B se Flood Elevation (BFE) data or base flood depth entered in 89.
1J FIS Profile L IRM 1J Community Determined iJ Other (Describe):
B11. Indicate the elevation datum used for the BFE in 139:1_-4-NGVD 1929 1J NAVD 1988 Ll Other (Describe):
B12. Is the building located in a Coastal-Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 1J Yes 1J.Nd
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: lJConstruction Drawings' 1JBuilding Under Construction* Finished Construction
'A new Elevation Certificate II jee 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, V1430, V (with BFE), AR, 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 th space provided or the Comments area of Section D or Section G, as appropriate, to docu e t the datum conversion.
Datum ConversioN,C�omme is
Ele "ion ref rence mark used v Z � Does the elevation reference mark used appear on the IR ? 1J Yes 1_1 No
U a) Top of bottom floor (including baseme t or enclosure) 7/ / ft.(m) 1i
❑ b) Top of next higher floor a _ ft.(m)
❑ Bottom of lowest horizontal structural member (V zon !) a _ ft.(m) o r
3 es only) d) Attached garage (top of slab) f 7 . a f -(m) E
❑ e) Lowest elevation of machinery and /or equipment
servicing the building _ ft.(m) E ,
E
O'fytowest adjacent grade (LAG) -7 . b ft.(m) z' E
g) Highest adjacent grade (HAG) f % ft.(m) 1 J
• h) No, of permanent openings (flood vents) within 1 ft. above adjacent grade n A '
• i) Total area of all permanent openings (flood vents) in C3h 1�2 /GQ 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.
be punishable by fine orimprisonment under 18 U.S. Code, Section 1001.
e, v
TITLE COMPANY NAME CE' TA C" "'
v ry-� p lI �—�
FL
O/
FEMA,F+rm A„._1 er ir- oo . \ SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use:
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number
CITY STATE ZIP CODE Company NAIC Number
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.
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.
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 LJJ ft.(m) 1_1_lin.(cm) L1 above or 1 -1 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 -1_I ft.(m) LLlin.(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 LI No L.I 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. 1-1 A community official -ompleted Section E for a building located in Zone A (without a FEMA- issued or community- issued BFE) or
Zone AO.
G3.1 I The following information (Items G4 -G9) is provided for community floodplain management purposes.
G4. PERMIT NUMBER G5. DATE PERMIT ISSUED 56. DATE CERTIFICATE OF COMPLIANCElOCCUPANCY
ISSUED
G7. This permit has been issued for: LI New Construction 1J Substantial Improvement
G8. Elevation of as41 t 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: _ fL(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