18450 NE 30 AVEFEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067 -0077
NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002
ELEVATION CERTIFICATE -�
Important: Read the instructions on pages 1 - 7. PEXYY►N�
SECTION A7 PROPERTY OWNER INFORMATION For Insurance Company Use:
BUILDING OWNER'S NAME Policy Number
BUILDING RE ADDRESS (Intl ding Apt., Uni Suite and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
�J ue u
CITY STATE ZIP CODE
/ES ` a m/ ei�d-q
PROPER DESCRIPTION (Lot and Block Numbers, Tax Parcel Number. Legal DescriDt�on otr. i
-- –• • •�• -• •�� numi&UN IAL UAi UM: SOURCE: U GPS (Type):
( #N. - #R - fqf.##" or ##.###f# °) -i NAD 1927 1-1 NAD 1983 LI USGS Quad Map 1_1 Other.
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
NITY NAM 8
rO
OMMUNITY NUMBER B2. COUNTY NAME
_ 1,9063 �.a m; - /? d
B3. STATE
ANEL
Y TAND
B5. SUFFIX
B8. FIRM INDEX
B7. FIRM PANEL
. FLOOD
69. BASE FLOOD ELEVATIONS)
b
DATE
� -)-,7 �
EFFECTIVEIREVISED DATE
1•_�I 9
ZONE S)
(
(Zone AO, use depth of flooding)
J
� 0
B10. Indic to }ho snurro of
fhc Ate— cl-
A o -
.___ - ._-- ...... p.1 -..' vaac n.l ucluu, unterea in tsa.
U FIS Profile ]_,J-FIRM �_J Community Determined L1 Other (Describe):
611. Indicate the elevation datum used for the BFE in 89: L,4- VD 1929 L NAVD 1988 U Other (Describe):
612. D the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? IJ Yes
Designation Date: � �O
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LlConstruction Drawings' I— (Building Under Construction' 1_fFlnished Construction
'A new Elevation Certificate will a 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, 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
calculation. Use the space provided or the Comments area of Section D or Section G, as appropriatex
conversion.
Dl efe Conversion/ comments
Elev tion r rence mark used U Does the elevation reference mark used appes No
a) Top of bottom floor (including basemen or enclosure) ft.(m) m ❑ b) TOp of next higher floor Bottom of lowest horizontal structural member (V zones only) _ ft.(m) ft d) Attached garage (top of slab) ° C\ ft.(m) E e) Lowest elevation of machinery and/or equipment servicing the building \ �yLowest adjacent grade (LAG) ft (m) =.P g) Highest adjacent grade (HAG) ft (m) fi ❑ h) No. of permanent openings (flood vents) within 1 R above adjac rttQ de
❑ i) Total area of all permanent openings (flood vents) in C3h 11 sq.-m. (sq. cm)
iz
OR
I his certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
/ certify that the information in Sections A, A and C on this Certificate represents my best efforts to interpret the data available.
I understand that any false stateWnt may be punishable by fine or imprisonment under 18 U.S. Code, Section 1 o01.
C/
W6
FEMA Form 81 -31 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS
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 agenticompany, 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 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 top of the bottom floor (including basement or enclosure) of the building is LLI ft.(m) LLlin.(cm) 1_1 above or LI 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_I -1 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? LI Yes Ll No Ll 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 hen:.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
1_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
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below.
G1. U 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. L A community offcaa! completed Section E for a building located in Zone A (without a FEMA- issued or community- issued BFE) or
Zone AO.
G3. l—J The following information (Items G4-G9) is provided for community floodplain management purposes.
G4. PERMIT NUMBER - G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCElOCCUPANCY
ISSUED
G7. This permit has been issued for: LI New Construction Ll 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
I I Check here if attachments
FEMA Form 81 -31, AUG 99 REPLACES ALL PREVIOUS EDITIONS