18470 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. 3
SECTION A - PROPERTY OWNER INFORMATION For Insurance Company Use:
BUILDING OWNERS NAME Policy Number
Apt., U ^it - Suite, agd(or Bldg. No.) OR P.O. ROUTE AND BOX NO.
Company
�1 IT i G /19 / - STATE O ZIP CODE
fl
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
BUILDING USE (e.g., Residential, Non - residential Addifion, PtccessoZ, etc. Yse Comments section if necessary.)
p/a 17 �+
LATITUDE /LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: LJ GPS (Type):
( ##° - ##' - ##.##° or ##.##### °) 1_I MAD 1927 1_I NAD 1983 U USGS Quad Map U Other.
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMUNITY NAME & OMMUNITY NUMBER
UDR t c/ � � li.j
B2. COUNTY NAME
�7i1i /7 i•- �
B3. STATE
�6h'i
64. MAP AND PANEL
BR
M INDEX
B7. FIRM PANEL
B8. FLOOD
69. BASE FLOOD ELEVATIONS)
NUMBER
0ps/
ATE
EFFECTIVE/REVISE DATE
ZONE(
(Zone A use depth of flooding)
_T
6 iv. indicate me source or tnStme mood Elevation (BFE) data or base flood depth entered in B9.
I FIS Profile LffFIRM LJ Community De, L_I Other (Describe):
B11. Indicate the elevation datum used for the BFE in B9: NGVD 1929 1J NAVD 1988 LJ Other (Describe):
B12. Is the building located in a Coastal-Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? LI Yes 1 p
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LJConstruction Drawings" IJBuilding Under Construction' I mished Construction
'A new Elevation Certificate will be required when construction of the building is complete.
C2. Building Diagram Number ,;6-44 (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, ARIAO
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 document the datum conversion.
Datum 44 y o Conversion/comments
Elevation r erence mark used COUrIy Does the elevation refere ce mark used appearon th FIR ? 1J Yes L1 No
&'a�) Top of bottom floor (including basement o r enclosure) fL(m) v
❑ b) Top of next higher floor !1 q , _R. m
❑ c) Bottom of lowest horizontal structural member (V zones only) n la . _ fL(m) o t
d Attached garage (top of slab) f -7 ft,(m) a t
❑ e) Lowest elevation of machinery and /or equipment w v '�
servicing the building Q4� . _ ft.(m) a /'
owest adjacent grade (LAG) i . O ft.(m) i N
Td'g) Highest adjacent grade (HAG) -7 ft. (m)
❑ h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade J2 1`Jl-j
❑ i) Total area of all permanent openings (flood vents) in C3h a42— sq. in. (sq. cm)
SURVEYOR, ENGINEER, OR
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
I car* that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available.
I understand that any false statemen(,tnay be punishable by fine or imprisonment under 18 U.S. Code. Section 100i_
"6R1r�i /Qi /UU /�Qe. z LICENSE NUMBER - - -_ _ - -_--- -_._
�l/X t'woe, / I -` - 13205 S W 137TH ta' .: 225
O/ .a"r '3o,/'-atra -0 96
Form 81�° \ 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
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 El 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 1JJ ft.(m) LI_lin.(cm) L1 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
LI -1 ft.(rn)1- 1— Iin.(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? J Yes l_I No 1_l 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_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. 1J 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. 1J The following information (Items G4 -G9) is provided for community floodplain management purposes.
G7. This permit has been issued for: 1_1 New Construction lJ Substantial Improvement
G8. Elevation of ss -built lowest floor (including basement) of the building is: _ fL(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