HomeMy WebLinkAboutFEMA Application 1985-12-18
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ELEVATION CERTIFiCATE'
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
AITENllON: Use of thIs pertificate does nol provfde a wafver of the flood Insurance purChase requirement Thls form Is used only to
provide elevaUon InformaUon necessary to ensure compliance wllh applicable community fIoOdplaln management ordinances, to ,
' determine the proPE!r Insurance premIum rate, arid/or.lo support a request for a Leller of Map Amandment or Revision (LOMA or LOMRj.
' Instrucllons for complellng ibis form can be found on the followIng pages.
SECTION A P'ROPERTY INFORMATION I FOR ~ECOMPANYUSe
eUILDINQ OWNER'S NAME POlICY NUMBeR
STREET ~OR.ESS (I~ Apt.. Unft., s,,?o ondIor ~ Numbo~ OR P.O. ROm AND BOX NlJMBER I COMPANY NAIC NUIl8ER
.;It.)<?b H~d~v-. \lyi....l~p (lot.<.d I
OTHER OESCRIPTION (lot end Blixk I/1pIjbots etc.) -.L
"Pa reel 2 ar [c..",c,( PClv+i '(014 Plat .A.)u......t!o..... Q[J-P05(o 7
CITY S P n ""'3 ~ -e. \ d-. STO f<.
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provfde the following from the proper FIRM (See Instruellons):
O.M.B. NoJ067./1l
EJlpireJMay31.1!
LAAJG
c.oU J.) r
ZIP CODE
t. COMMUNITY NUMBER 2. PANa NUMIlER 3. sumx 4, OATE OF FIRM INDEX 5. FIRM ZONe 8. BASE FlOOD ELEYATlON
{'J {klAOZonoo,usodlplllJ
415S~1 0370 C ~c(o)19B5ACo 1./5'l3
7. Indlcate the elevaUon datum system used on the FIRM for Base Flood E1evaUons (BFE): M'NGVD '29 OOther (describe on back)
8. For Znnes A or V, where no BFE Is provided on the FIRM, and the communlly has established a BFE for this bulldlng slle, Indicate
.' the community's BFE: I I , I I I.U feel NGVD (or other FIRM daturn-see Seellon B, ltem7).
SECTION C BUILDING ELEVATION INFORMATION
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1. Using the Elevation Certificate Instruellons, Indl~he diagram number from the dlagrams found on Pages 5 and 6 that best
describes the subject bufldlng's reference level .' ,
'2(a). FI~7 t~~~l'A30, AE, AH, and A (with BFE). The top of the reference level Roor from the selected dtagram Is at an elevation
of 5.111 feel NGVO (or other FIRM daturn-see Section B, Ilem 7).' ,
(b). FIRM Zones V1-V30, VE, and V (with BFE). The bollom 01 the lowest horizontal structural member of the reference level from '
(he selected dlagram, Is at an elevation of U I I U.U feel NGVO (or olher FIRM dalurn-see Section B, lIem 7).
'(e); FIRM Zone A (without BFE). The floor used as the reference lev~llrom the selected diagram Is W.U feet ~ove 0 or
below 0 (chaok one), the highest grade adjacent to the building.
(d). FIRM Zone AO. The fioor used as the reference level from Ihe selected diagram Is W.U feet above 0 or below 0 (check
one) the highest grade adjacent to the building. II no Rood depth number Is available, Is the building's lowest floor (reference
,level) elevated In aCCOrdance'wlth the communIty's f100dplaln management ordlnanc~? DYes 0 No 0 Unknown
3. 1,,~I_;~'the elavaUon datu~ system used In determining I~ a~ve reference leve! elevaUons: gj NGVO '29 0 OIh~r (descnbe
under Comments on Page 2). (NOTE: If fhe e/eval/on daium used In measuring fhe elevations Is dIlfarenf fhan that used on
the FIRM (see Section B, /fem lJ, then convert the e/eval/ons 10 fhe datum syslem used on Ihe FIRM and show the co", o. 0...1
equallon under Comments on Page 2.) ,
4. E1evaDon reference mark used appears on FIRM: 0 Yes Dlf No, (See Instruellons on Page 4)
5. The reference level elevaUon Is based on: ~ actual construcUon, 0 construellon drawings, '. ,
(NOTE: Use of constnJc//on drawings Is only vand If the building does nof yel havs the reference level floor In place, in which
OSSe this certificate win only be valid for the building during the course o( a>nslrucllon. A posl-aJnstrucl/on Elevation Certincale
WJ71 be required once construe/Ion Is complete.) ,
8, The elevaUon of the lowest grade Immedl,alely adjacent to the building Is: u1IJZJQJ.~ feet NGVD (or other FIRM datum-see
Seellon B, 119m 7). '
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SECTION D COMMUNITY INFORMATION
1. II the communIty official responsible for verifying building elevations specines thet the reference level Indicated In Seellon C, Item t
Is not the 'owest floor" as deRned In the community's Roodplaln management ordinance, the elevaDon of the buildIng's "lowest
noo.. as deRned by the ordinance Is: I I I ", I ,U feet NGVO (or other FIRM datuID-See SectIon B, Item 7).
2. Dele of the start of construellon or subsl9nUallmprovement
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' ThIs certlficaDon Is to be sIgned by a land sunieyor, engIneer, or archfieci Who,1s authorized by slate 0( iocaJ law 10 celt/ty elevatlon
InformaDon when the elevaUon InformaUon for Zones A1-A30, AE, AH, A (with BFE),Vt-V30,VE, and II (with BFE) Is required. '
Community olflclals who ~ authorized by local law \II' ordlnance to provfde ftoo$IaJn managemen\ lnformallon, may also sIgn the
certlficaDon. In the case ot Zones AQ and A (without a F~ or CQIllmunlly issUed BFE), a buUdlng ofliclaf, li property owner, or an
owner's representadve may also sign thl! celt/ftcadon. ,
SECTION E CERTlFlCAnON
Reference level diagrams 6, 7 and 8 - Dlsdn9uJshlng Fealures-/f the certffler Is unSble 10 caItlty 10 breakawaYln~reakaway wen.
I!nclosure size, location ot servfcfng aqulpmen~ area use, wall openings, or unfinished area Feature(s), then flstthe Fealure(s) not
Included In the certlficadon under Comments below; The dlagrem number, S8Cllon C, lIem 1, must sWI be entered. ",' , . ' . .
I certify Ihatlha Information In Sections-Band C on /his C8rt/f/cata /'Bpt8S8nls my basteffotts /0 Intel'pfetlha data available.
I understand that any false statement may ba PUnishable by fine or Imprisonment under 18 U.S. Code, SBctIon 1001.
CERTIFIER'S NAM\l.r--.. UCENSE NUAIIlER (or AIIfx Seal) , '.,
' 'Kex AIle", J:>et'2- 'FLs, '2(oO(PEJ<.o,ye.s: ,zI?,,/9S"
COI.tPANY NAMe
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ADDRESS
. 310 Doy~ Stl-i 'St.
SIGNATURE '
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Cop/es ahould be made ot thIs CertIficate tor: 1) co~unlty off/ctal, 2) b1auranca egent/company, and 3)!IuJldlng owner.
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The diagrams above Illustrate the points at whIch the etevadons should ba measured In A Zones .~ V Zonas.
Elevadqns for all A Zones should ba measured ,at the lop of the reterence level ftcor.
Elevations (or !Ill V Zones should be'mwured a1the boitom of the lowest horlzont.alatruclural member.