18460 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 es I - 7. WAVV -%► VAS O
SECTION A - PROPERTY OWNER INFORMATION For insurance Company Use:
BUILDING OWNER'S NAME PolicyNumber
BUILDING STRE T ADDRESS (Indudin Apt., Unit, S de and/or Bld . No.) OR P.O. ROUTE AND BOX NO. Company NAIC Number
O .0 C� ve /J v
CITY /91 Q m STATE / <� Q /� ZIP CODE
9
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
BUILDING USE (e.g., Residential, Non - residential di8on, A'9sso etc. Use gomments section if necessary.)
/'f eSideA)t /
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: U GPS (Type):
( ##° - ##' - ##.##" or ##.##At## °) 1_I NAD 1927 LI NAD 1983 LI USGS Quad Map I_I Other:
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
1. FIP COMMUNITY NAME & r,014MUNITY NUMBER
.206.35
B2. COUNTY NAME
B3. STATE / .�
QL�
B4. MAP AND PANEL
B5. SUFFIX
B6. FIRM INDEX
B7. FIRM PANEL
B8. FLOOD
B9. BASE FLOOD ELEVATION(S)
NUMBER
aoar 6aP
DATE
17-17-9p.5
EFFECTIVE/REVISED DATE
ZONN-E(((S
(ZoneA�usG depth of flooding)
-C
3- ,7 -9sZ
177
(>
B10. Indicate the source of the ase Flood Elevation (BFE) data or base flood depth entered in 89.
I_I FIS Profile I, FIRM LI Community D ined LI Other (Describe):
611. Indicate the elevation datum used for the BFE in 89: J NGVD 1929 IJ NAVD 1988 LI Other (Describe): _
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?
Designation Date:
I —I Yes In!hNo
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LlConstruction Drawings' LJBuilding Under Construction" I finished Construction
`A new Elevation Certificate III 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, ARIA, 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 th space provided or the Comments area of Section D or Section G, as appropriate, to documen th datum conversion.
Datum Conversion /Co marts
Elevation re rece n mark used Does the elevation refere mark used appear on the FI ? IJ Yes LI No
a)) Top of bottom floor (including basement or nclosure) ! ft.(m)
❑ b) Top of next higher floor _ ft.(m) a
❑ c Bottom of lowest horizontal structural member (V zones only) ft.(m)
d) Attached garage (top of slab) fi 7
❑ e) Lowest elevation of machinery and /or equipment
d servicing the building_
owest adjacent grade (LAG) t —7 ft.(m) z' jA \�
g) Highest adjacent grade (HAG) / % ft.(m) (
❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade "
❑ i) Total area of all permanent openings (flood vents) in C3h n A 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 cattily that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available.
/understand that any false_ statemepj maybe punishable by fine or imprisonment under 18 U.S. Code. Section 1001.
TITLE COMPANY NAME
Sv�A10✓ _ IC-- 5SW7377[] iF: 225
SEE REVERSE SIDE FOR CONTINUATION
REPLACES ALL PREVIOUS
IMPORTANT: In these spaces, copy the corresponding information from Section A. I For Insurance Company Use: I
CITY STATE
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_1 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 1_I -1 ft.(m) LLlin.(cm) J_I above or I_J 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 —I-1 ft.(m) 1 _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
official must certify this
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
LI 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 completed Section E for a building located in Zone A (without a FEMA- issued or community- issued BFE) or
Zone AO.
G3. 1 —I Tha following information (items G4-G9) is provided for community floodplain management purposes.
_ I I ISSUED
G7. This permit has been issued for: I —I New Construction LI Substantial Improvement
G8. Elevation of as -bulH 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