HomeMy WebLinkAboutFEMA Application 1995-7-24
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-.- JUL 24 '95 14:57 BOUCHER/MOUCHKA -
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, . - ' '," ELEVATION CERTIFICATE
'FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM ,
ATTENTION: Use 01 lhl8 c:artlflcale does nor provide a warier of the flood Insurance purchese reClllfrement.'11da:iorm 18 uaed only to
provide elevation InformaUon Il9C8saary 10 ensure compliance with appnc:able communlty floodplain management ordlnenc:vs, 10
delermlne lhe proper Insuranc:v premium rale, and/or 10 support a request for a Leller 01 Map Am"ndmenl or R,evfslon (LOMA or LOMR).
'InstructIons lor compfellng thIs torm can be lound on the followIng pag.... ; . ,C,"
P.3/4
0.M.I1.I<I01067.oo77
fapi,..Mfy1" "91
SECTION A PROPERTY INFORMATION
eUl\.OlNG OWNER'S NAIIE , , '
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STR';:! AOORESS (1)lcIudI(lg Aot. UnIl. SullO andfo, BIdo. N.......' oil' P.O. ROUT,E'AHD BOll NUMBER
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OTl<eR DESCRIPTION (1;,1 and _ Nlnnbore, etc., I
FOR ":'8l-,uce COMPNtr uaE
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CllWWCY NAIC NUIoIIIER
CITY Sro..-', VI ~ ft'eJ J..
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, S,ECTlON $
STATE ,/)
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FLOOD INSURANCE RATE MAP (FlRM) INFORMATION
,ZIPCOOE
q74-77
ProYida the 1000..lng ,rrom the proper FIRM (See Inslruellons):
1. CONUUNtTV N\JM8EA t. PANE\. NUMBER I 3. SUFFJ)C 4. DATE OF FIRM INDEX a FIRM ZONe ... BASI FLOOD &.LEVAfJOH
,a (IIlAOz-."_1
4 155'1/ CETo C- De.e 18) '-185 AU> 427. G>
7. Ind1cale the elevation datum syslem used on the FIRM lor Base Flood Elevallons (BFE): $,NGVD '29 0 Other (descrtbe on beck)
B. For Zones A or V, where no BFE Is provided on Ihe FIRM. and Ihe communlly has established a BFE'lor Ihl8 buUdlng silo. Indicate
Ihe community's BFE;I I, I , I I.U feel NGVD (or olher FIRM daMn-see Section B. lIem 7). ' . , ..
SECTION C' BUILDING ELEVATION INFORMATlON
I., Using the Elevallon Cerllncale Instructions. IndIcale ihe diagram number from the diagrams found on Pages 5 and e thai bast
, , ' . descrtbes the subject building's reference level--L- . " ' ,
2(a). FIRM'Zon95 Al'A30. AE. AH. and A (wllh BFE). The lop of Ihe relerence level Roor Irom the selected 'diagram Is at an elevation
011 I till ~.IQ feel NGVD (or other FIRM datum-see Secllon 8. llem 7). ,
(b). FlRM Zonlls Vl-V3D, VE. and V (with BFE). The bollom or the lowe.t horizontal .1ructur8l member 01 Ihe reference level from
lhe selected diagram, Is at an et9V8t1on of I I I I I I.U feel NGVD (or olher FIRM dalum-see Section B, Ilem 7).
(c). FIRM Zone A (wilhoUI BFE). The 1I00r used as the reference levellrom lhe Seleel'";;d diagra';' Is W.U feel above 0 or
below 0 (check one) the highest grade adjacenllo Ihe building.
(d). FIRM Zone AO. The IIoor used as Ihe refe;ence levellrom\he-';'Iected diagram is W.U Is'el abo~'O or below 0 (check
one) the highest grade adlacenllo the building. 'If no 1I00d deplh number Is available. Is the building's lowest floor (reference
level) elevsted in accordance wilh lhe community's lloodptain managemenl ordinance? 0 Yes 0 No 0 Unknown
3. Indicale the efllVlliio~ datum syslem used in determining the above relerence level e'evauons~GVD''29 0 Olher (describe
under Commenl8 on Page 11). (NOTE: If the e/eva/ion datum used in measuring the elevations is differenllhan thaI used on
the FIRM (see'S6cllon B. Ilem 7], then con""rr the elevations to the datum system used on the FIRM and show rhe conversion
equation und8r Comments on Page 2.)
4. Elevation reference mer1< used appears on FIRM: 0 Yes ~NO (See Instrucllons on Page 4)
5. The reference 18V81 elevallon is based on: $aclual conslruellon 0 conslruCllon drawings
(NOTE: Use 01 constlUctlon drawings Is only valid il the building does Il<ll yet have the refereflCfl level floor In place, In which
case this cerrlficate will only be valid for the building during the eDurse of constlUclion, A post-constlUcrion Elevation Cerrlflca/e
will be required once eDos/lUC/ion is complete.) ,
6. The elevation of the lowesi grade Immediately adjacent 10 lhe building Is: U fit Z~, i!h teel NGVD (or other FIRM dalum-see
Secllon B, lIem 7).
SGCTION D COMMUNITY INFORMATION
1. " the communily official responsible lor verilying building elevallons spocilles Ihatlhe reference levellndicaled In ~_..I... C, Item 1
, Is nolthe "Iowe.llloor' as defined In the community's 1I00dplain managemenl ordInance. the "Ievallon ollne OUIICllng's "lOwest
lloor" as defined by Ih~ ordinance is: I I I I I I.U feet NGVO (or other FIRM dalum-<;ee Secllon B, Item 7).
2. Dale of the Slart or construction or subsCantiaJ improvemenl
fEMA JormS1.J', MAY 90
REPLACES All PREVIOUS EDITIONS
SEE REI/ERSE SICE FOR CONTINUATION
JUL 24 '95 14:57 BOUCHER/MOUCHKA
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SECTION E CERTIFICATION
this cenJlIcadon Is tD be signed by a land surveyar, engineer, or BtCIIItllC\ who Is audlortzed by slata or loc:aJ law IA,-dly elevaIlon
Infannatlon when !he elevation InlormatIoiI far Zonllll Al-A30. AE. AH. A (with BFE),Vl-V30,VE. and V (wItfl BFE) Is naquInJd.
Community olflclala who are aulhortzad by lacallaw or ordinance 10 provide fIoodplafn meftllQlllll8l1llnlonneilon, may also elgn l/le
c:vrllllcstion. In "'e case of Zones AO and A (wtthoul S FEMA or communlly IsSllllG BFIi), a bulldlno oIIIcIal, li propeny Owner, or Bn
ownar's reprss8nl8dv8 meyalso sign IIIe cettllIcadon. , ,_.. "-
Relerence level diagrams 8, 7 snd 8 . Dlstlngulshfng FaalUre;'U l/le eertlller Is unable to certlly to bnrakawsll-' , ' , ,. _ WIly wan,
enclosure siZe. locaIlon of servicing Gqulpmen~ Bt8a use. wall openings, or unflnlslled lIr8a Fe8lunl(sl, then Ust 1hit~ailuie(s) nOI
Included in Ihe cen/llcalJon under Comments below. The diagram number, Sec;llon C, Item I" ~ sID! ~.. ~IIl1.' ~;:' . \: :" .. , . .
. . ".... .....:>.:.'...;;...~::d:::.~;:-.:.~.. ......
J C8fI1/y lhallha IntormsJIotl{n Secticns 8 aird C on Ihls C81IIflcalB fflpi'e58nts my b851e{(ofts 10 1n18fPre11hB /tara aviJJabIe. "
I und8rslan~ Jhal any bJ/58 SIBlBIII81It mayb8 punishable by IIn8 or imprisonmenl und1Jr 18 /).5: CtJdIj.. ~,100~.:-.:;': ':,:: ,: '
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CEIlTIFIER'SHAIoll!-o + UCENSENUIoIllERlorAIIIIllool) , . .... E"'(:>lv~S'
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TITU!.. rprc)~:ec.tS~;;ve<.{~r: ,,' COMPAHY~'::BY'aY1':~':~~~^,~r.'i\:i _....__.... ':: ' .. ,
ADDRESS .... , I CITY 'ilrA~ ZIP'
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SlGNAT\JRE '.._~ _(?,R~' ~ o..~ b" /9S\.:':'~so3) 74t, ~'O~3 7
Copies Mould be made olthla CettlflCllla lor: 1) community olllclal, 2) lnaurance egenllcomP8:ny; ailll3)'buRdlng Owner.
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ot 4'?:l1. 24: k)l;,/O "1I1 W{,,:~ '-~ c..<. -tl.o. ~bC::l"- ;;+=F-'r~::.iI~i,~<:.
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The diagrams above IlIusllsle the poinls sl which the elevadons should be maasurad In A ZOO8S and V Zones.
Elevations 'tor aU A Zones should be measured al the lop 0' the reference level floor,
Elevations 'or all V Zones should be measured atlhe botlom of the lowest horizontal slruc1UraJ member.
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