The URL can be used to link to this page

Home My WebLink AboutFEMA Application 1999-6-2 ~ FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE Im;oortant: Read the instructions on ;oapes 1 - 7 SECTION A - PROPERTY OWNER INFORMATION BUILDING OWNER S NAME ~t2..uCk- "'-' l EC-~EA'VI c....U?-;-OM t~)~\A.~ BUILDI/>JG STREET ADDRESS (Including Apt, Umt, SUite, and/or Bldg No) OR P 0 ROUTE AND BOX NO q ~ (0 b ~ ""'?~;...E- T CITY STATE ?~l2.{/.J4:(=l~ De- PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Desenpbon, ete ) toT 5'5 U2.ML ~Dd..l.b 0I:L. ~~. "Fl<.h.- IS.<SL1()~ IlS2-IlSS BUILDING USE (e g , Resldenbal, Non-resldenbal, Addition, Accessory ete Use a Comments area, If necessary ) ~~l t:>Eu.TIA-L- LA TITUDElLONGITUDE (OPTIONAL) ( It#' - ##' - #:II ##" or ## ####If) o M B No 3067-0077 Expires July 31, 2002 For Insurance Company Use .policy Number Company NAlC Number ZIP CODE q/4"'~ ~~ (D ?t.A1~-lI; HORIZONTAL DATUM L-I NAD 1927 1-1 NAD 1983 SOURCE 1-1 GPS (Type) 1-1 USGS Quad Map 1-1 Other SECTION 8 _ FLOOD INSURANCE RATE MAP (FIRM) INFORMATION I B1 NFIP COMMUNITY NAME & COMMUNITY NUMBER-I 82 COUNTY NAME 83 STATE ~V \2.t \..l.b.B E.Lh 4l SSqL.- I l.- klJ.E- o-t2- B4 MAP AND PANEL B5 SUFFIX B6 FIRM INDEX B7 FIRM PANa B8 FLOOD B9-BASE FLOOD ELc\lATION(S) . NUMBER -f- DATE EFFECTIVElREVISED DATE ZONE(S) (ZoneAO, use depth oftloodmg) 4l()?qvlllOt "\- 0-'2--'('1 0. "2-9C, .~~~7'- CS\"'Z.-\- B10 Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered m B9 I I-I FIS Profile I_I FIRM ~ommunlty Determined LI Other (Describe) B11 Indicate the elevation datum used for t 1e BFE In B9 I_I NGVD 1929 I-J NA VD 1988 ~ Other (Describe) L.OC.A-t..; B1" IS the bUilding located m a Coastal Barner Resources System (CBRS) area or Otherwise Protected Area {OPAl? 1-1 Yes 1-1 No eSlgnatlon Date SECTION C _ BUILDING ELEVA TJON INFORMATION (SURVEY REQUIRED) C1 BUilding elevations are based on I-I Construction Drawmgs" 1_IBUlldmg Under Construction" ~mlshed Construction "A new Elevation Certificate Will be reqUired when construction of the bUilding is complete C2 BUilding Diagram Number Z- (Select the building diagram most Similar [0 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 A 1-A30, AE, AH, A (With BFE), VE, V1-V30, V (with BFE), AR, ARiA, ARlAE, ARIA 1-A30, ARiAH, ARlAO Complete Items C3 a-I below accordmg to the bUlldmg diagram speCified in Item C2 State the datum used If the datum IS different from the datum used for the BFE m 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 ~ Conversion/Comments ~b O::z.,( '1\) L..CLA:-c- !)A'nIM \0 ~ 'Fe '^ A DA-I'\),4'\ . Elevation reference mark used ~E.- C~AALU.L.~. Does the elevation reference mark used appealfn the~.r:d?~~*~~ o a) Top of bottom floor (including basement or enclosure) Sl-=?.k.. ft ~ -: '1' rrl ;~. ,. ::.;\~~ !'i..",~..Il;,L. ~ o b) Top of next hIgher floor 6"llo Je....ft~ ~ L,ll,r-..:D uU:'<.~g~\..o~ : o c) Bottom of lowest horIZontal structural member (V zones only) W,./A- - ft (m) : ~ ...... "'" ........,.... ........ ....... .. -.. ~ o d) Attached garage (top of slab) 5\c3 .2 ft ~ ~ 1? \ If1 A fl ( o e) Lowest elevation of machinery and/or equipment ~ ~ ~d'~ it-~.u servicing the bUilding (Descnbe m a Comments area) S l S 4- ft t-\ ~.3 v............ ,_u.__._~ - ~ E III . 0' *,o;~-.j :V o f) Lowest adjacent (finished) grade (LAG) S \4 ?;> ft ~ ~.Eo ; J;)' r~:,_ ;.>.~ o g) Highest adjacent (finished) grade (HAG) ?l't- ~ ft (~ ~ en ., JONP\~ H;~ .l\ O.zJ<ES o h) No of permanent openings (flood vents) Within 1 ft. above adjacent grade. t 4-- ~ ,-,.. .... ..~..: ;-.~~ o I) Total area of all permanent openmgs (flood vents) in C3 h t Sq ~ sq in (., -r- ~,..~, --fi::..-;-...;;.. ~"' ::..:- SECTION 0 _ SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICA nON ThiS certification IS to be Signed and sealed by a land surveyor, engineer, or architect authOrized by law to certify elevation information I certify that the mformatlOn m SectlD.,ns A, 8, and C on thiS certificate represents my best efforts to Interpret the data available I ur --stand that an false statement a e pUnishable b fine or Imprisonment under 18 U S Code, Section 1001 --cE. ER'S NAME I 1\\ \ l-:: LICENSE NUMBER . . ---.J O~t+A\..i '7 Df"l_ L- '::;:> ~"Zl oS TITLE COMPANY NAME P ~t.. '"h{ o'"-A-L. L~t) C;;;v'-f2.)J C. 'fl)t2- ~oM. t- ~b l t-L efA2J.l-.lL. ADDRESS CITY STATE ZIP CODE v.O,:"bOY-- XS'2...:1 ~4.~0E.- 0f.2- q,4-C"2- SIGNATURE \,., 10' _ / { ~ DATE TELEPHONE ---.J~ lW'U \ Z-t-O"? '54t - 41::::>5 4SCS =I=MA Fnrm R1_~1 JIll nn c::.FF: RF\/FRc::.F c::.lnF FOR rONTINllATION RFPI ArFc::. AI I PRFVIOII<:: FnITION<:: . ,... 'PORTANT In these spaces, copy the corresponding ,"fonnatlon from Section A A.JILDING STRF~ ADDRESi' (Including Apt, Unrt, SUite, andlor Bldg No) OR P 0 ROUTE AND BOX NO q~ lbb--U=?\ l2-~ CITY STATE ZIP CODE Company NAIC Number ?Pt2-I~6F\~ L>l.2- en4-z~ SECTION D . SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) I For Insurance Company Use Pofrcy Number Copy both sides of this ElevatIOn Certificate for (1) community official, (2) Insurance agent/company, and (3) bUilding owner COMMENTS c....lT'i ~ ~PI2-\J.16~\ ~ ~c..+\~~ 'De..~c...\o2..tl ~ 6. L.+"-I.~tc-t.II '?O..~ . I \U Tlkf_1bl' OF~ UJrU':l ~ ~ r\ALl) P01U.T 6F ~ ~ ~l2.1J kT ~ ~1H\t1~ ~€AZ- ex: n1-€- llJ.. T€'(2f::;iZ:~.T 10l-t OF (01 ill- TV? 1tl t! ~ 'tLB--f. S \"2.. ~ \ I J Check here If attachments SECTION E _ BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zone AD and Zone A (without BFE), complete Items E 1 through E4 If the Elevation Certificate IS rntended for use as supporting rnformation 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_1_1 ft (m) 1_1_)m (cm) I-I above or I-I below (check one) the highest adjacent grade (Use natural grade, If available) E3 For BUlldmg Diagrams 6-8 With openings (see page 7), the next higher floor or elevated floor (elevatIon b) of the bUilding IS 1-1-1 ft (m) 1_1-11n (cm) above the filghest adjacent grade Complete Hems C3 hand C3 I on front of form E4 For Zone AD only If no flood depth number IS avaIlable, /s the top of the bottom floor elevated In accordance With the community's floodplain mana~ement ordinance? I I Yes I ! No I_I Unknown The local offiCial must certify thiS rnformatlon In Sect/on G SECTION F _ PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owner's authonzed representative who completes Sections A, 8, C (Items C3 hand C3 I only), and E for Zone A -thout a FEMA-Issued or community-Issued BFE) or Zone AO must sign here The statements In SectIOns A, B, C, and E are correct to best of mv knowledge r-ROPERTY OWNER'S OR OWNER S AUTHORIZED REPRESENTATIVE S NAME CITY STATE ZIP CODE ADDR~;; SIGNA"-j-UK~ DATE TELEPHONE coMMEr,ji; I Check here If a~achments The local offiCial who IS authonzed by law or ordinance to administer the community's floodplam 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 mformat/on m Section C was taken from other documentation that has been Signed and embossed by a licensed surveyor, engmeer, or architect who IS authOrized by state or local law to certify elevation mformatlon (Indicate the source and date of the elevatron data In the Comments area below) G2 1-1 A community offiCial completed Section E for a bUilding located m Zone A (WIthout a FEMA-Issued or communrtY-lssued BFE) or Zone AO G3 I_I The follo~mg mformatlon (Items G4-G9) IS prOVided for community floodplain management purposes G4 PERMIT NUMBER - SECTION G _ COMMUNITY INFORMATION (OPTIONAL) I G6 DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED I G7 ThiS permit has been Issued for I_I New Construction I_I substantrallmprovement G8 Elevatron of as-burlt lowest floor (including basement) of the bUilding IS G9 BFE or (In Zone AO) depth of flooding at the bUilding Site IS LOCAL OFFICIAL'S NAME I G5 DATE PERMIT ISSUED _ ft (m)Datum _ ft (m)Datum TITLE TELEPHONE COMMUNITY NAME DATE IA TURE COMMENTS , Check here If attachments RI=PI Arl=C:: AI I PRI=\llnl Ie:: I=nlTlnNe:: - =I=MA Fnrm R1_ 'H II II nn