18465 NE 30 AVEFEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067 -0077
NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002
ELEVATION CERTIFICATE
the instructions on oaaes 1 -7. n\ —
SECTION A - PROPERTY OWNER INFORMATION ( For Insurance Company Use: (
BUILDING STR Ej ADDRESS (Induder�9 Apt., Unit, Suit and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. I Company WC Number I
�i�('9 t� .(% C� .�Z% �UPhU�
CITY STATE >-+ /_ _ / ZIP CODE
and
<n
LA I I I UUE/LONGITUDE (OPI ZONAL) HORIZONTAL DATUM: SOURCE: LI GPS (Type):
( ##° - ##'. ##.#r or ##.tpr # °) LJ NAD 1927 L-1 NAD 1983 1 -1 USGS Quad Map L_J Other.
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. FIP COMMUNITY 8 COMMUNITY NUMBER
B2. COUNTY NAME
B3. STATE /
".Gio'
cv.0 fzt
B4. MAP AND PANEL
B6. SUFFIX
B6. FIRM INDEX
B7. FIRM PANEL
B8. FLOOD
B9. BASE FLOOD ELEVATION(S)
NUMBER
DATE _
EFF CTIVE/REVIS DATE
3
ZO E(S
j
(ZoneA u depth of flooding)
/a2o,,r 06,?
/7 -9
-a -9
B10. Indicate the source of the .Base Flood Elevation (BFE) data or base flood depth entered in B9.
1_1 FIS Profile I_ IRM IJ Community Determined L_1 Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: L,!�J_N_GVD 1929 LI NAVD 1988 1 1 Other (Describe):
812. Is the building located in a Coastal-Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? jJ Yes IJ No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LlConstruction Drawings' IJBuilding Under Construction" finished Construction
`A new Elevation Certificate yw 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, 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 aA datum conversion
calculatio . Use_ t space provided or the Comments area of Section D or Section G, as appropriate, to docum nt a datum conversion.
Datum ConversioqtComm it
Elevation re rence mark used 0 4 � Does the elevation referen mark used appear on the I M. 1J Yes L_1 No
m
Top of bottom floor (including basee t or enclosure)
❑ b) Top of next higher floor A , ft.(m) ,
❑ 5) Bottom of lowest horizontal structural member (V zones only) n _ ft.(m) A q
d) Attached garage (top of slab) 4 77 ft.(m) 1-
❑ e) Lowest elevation of machinery and /or equipment w
servicing the building n Za _ft.(m) E
o vest adjacent grade (LAG) t % . O ft.(m) i W
C3 g) Highest adjacent grade (HAG) "7 ft.(m) g y \ V
C ❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacen grade U ')
• j) Total area of all permanent openings (flood vents) in C3h � 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 e vation information.
I certify that the informaSon in Sections A, B, and C on this certificate represents my best efforts to interpret the data'avaiiable.
I understand that any false state t may be punishable by fine orimprisonment under 18 U.S. Code, Section 1001.
CERT NW TM q6y t7 LICENSE NUMBER
TITLE d r COMPANY NAME I DELTA SUIRVEYOn t "^
ADDRESS CITY 139=0 W 137TZIPXVDEf-
DATE p / TELEPHONE �IJ ✓-'d �.�-O�%O/
SEE REVERSE
IMPORTANT: In these spaces, copy the corresponding information from Section A. I For Insurance Company Use: I
CITY
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.
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 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 1 -1 -1 ft•(m) I_I— lin.(cm) L above or 1_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
LEI 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 1_1 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. 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.)
132. LI 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. LI The following information (Items G4-G9) is provided for community floodplain management purposes
G4 P RM 7 JtUMJ G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
ISSUED
G7. This permit has been issued for: LI New Construction LI 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
SIGNATURE DATE
Check here if attachments
FEMA Form 81 -31, AUG 99 REPLACES ALL PREVIOUS EDITIONS