HomeMy WebLinkAboutElevation Certificate
,.J
~
ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM .
e.TTENT10N: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to
Jrovide elevation information necessary to ensure compliance with applicable community floodplain management ordinances. to
determine the proper insurance premium rate. and/or to support a request for a Letter of Map Amendment or Revision (LaMA or LOMR).
Instructions lor completing this form can be lound on the following pages.
0.M.8. No 3067-0077
E)(pir~sMay31. 1993
SECTION A PROPERTY INFORMATION
FOR INSURANCe COMPANY USE
POLICY NUMBER
eUILOI~~G OWNEE~:R\ ()-\\-e. \\c-e... ~ ~
STRE"T ADDRESS (l.nCiucing :pc.. Unit. SUlfB andler 8ldg. NumcerJ..9l?-f'O. ROUTE AND SOX NUMBE::1
\ ~"?J2:"Z...._w'RE" OPt-~S i\ofr..()
WHE::1 Of SCRIPTION {Lot and 810cI< Numcers. eIC.)
y (0 \ o\- 2q I Lo\-s?JO,?> \; '?>L., '":)3
CITY ()
\"'R~.:,(Q. Gv-~ \
COMPANY NAIC NUMBEA
{{r-o
Llt:>. \<.;
I
STAT::
ZIP CODE
SS~I2-
MN1
SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provide the following tram the proper FIRM (See Instructions):
I. COMMI;NITY ,'~UMBER 2. PANEL NUM8EA J. SUFFIX 4. OAT: QF FIRM INOEX 5. FIRM ZONE 5. SASE FLOOD :L5VATlON
{\ (In AO zones~e ~;n)
'2. ( 0 \-\ ~"2- 000 i..\ :, ~, _~ ~_ ,l \ \ - \ ~ -:1 'i.., ~;:e:;R' o~\ ~,,~~ r\c(, V\
7. Indicate the elevation datum system used on the FIR~1 for 6ase Flood Elevations (sr-~~; ~ NGVQ '29 ,~O:h~{~,e;;9cibe 9n back)
8. For Zones A or V, where no BFE is provided on the FIRM. and the community has established a BFE for this building site. indicate
the community's BFE: ,q O<O:,~ feet NGVO (or other FIRM datum-see Section B. Item 7).
SECTION C BUILDING ELEVATION INFORMATION
~. Using the Elevation Certificate Instructions. indicate the diagram number from the diagrams found on Pages 5 and 6 that best
.., describes the subject building's reference level \ .
.::(a). FIRM Zones A 1-A30. AE. AH. and A (with BFE). The top of the reference level floor from the selected diagram is at an elevation
of . _ feet NGVD (orother FIRM datum-see Section B. Item 7). .
(b). FIRM Zones V1-V30. VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level from
the selected diagram. is at an elel/ation of: ! i I I I.;~ feet NGVD (or other FIRM datum-see Section B, Item 7). .~
(c). FIRM Zone A (without BFE). The f10er used as the reference level from the selected diagram is :.U teet above. or
below _ (check one) the highest grade adjacent to the building.
(d). FIRM Zone AO. The floor used as the reference level from the selected diagram is ; ~. ~ feet above n or below Ii (check
one) the highest grade adjacent to the building. If no flood depth number is available. is the building's lowest floor (reference
level) elevated in accordance with the community's floodplain management ordinance?, : Yes ' No 1-1 Unknown
3. Indicate the elevation datum system used in determining the above reference level elevations: )s:; NGVD '29 ~ Other (describe
under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is different than that used on
the FIRM (see Section B. Item 1], then convert the elevations to the datum system used on the FIRM and show the conversion
equation under Comments on Page 2.)
4. Elevation reference mark used appears on FIRM: I-.J Yes ~No (See Instructions on Page 4)
5. The reference level elevation is based on: :~ actual construction 0 construction drawings
(NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which
case this certificate will only be valid for the building during the course of construction. A post-construction Elevation Certificate
will be required once construction is complete.)
6. The elevation of the lowest grade immediately adjacent to the building is: I :'\i 01 Ll.'"'?! feet NGVD (or other FIRM datum-see
Section B. Item 7).
SECTION D COMMUNITY INFORMATION
e
If the community official responsible for verifying building elevations specifies that the reference level indicated in Section C. Item 1
is not the "lowest floor" as defined in the community's floodplain management ordinance, the elevation of the building's "lowest
fleor" as defined by the ordinance is: Ii: i i I,U feet NGVD (or other FIRM datum-see Section 8. Item 7).
2. Date of the start of construction or substantial improvement
FEMA Form 81-31J MA Y 90
REPLACES ALL PREIJIOUS :DITIONS
SE: AEVE;:;SE SIDE ~OR CCNTINUAT;CN
SECTlON E CERTlFICATION
e This certification is to be signed by a land surveyor, engineer, or architect who is authorized by state or local law to certify elevation
information when the elevation information for Zones A1-A30, AE, AH, A (with BFE),V1-V30,VE, and V (with BFE) is required.
.Community officials who are authorized by local law or ordinance to provide floodplain management information. may also sign the
certification. In the case of Zones AO and A (without a FEMA or community issued BFE), a building official, a property owner. or an
owner's representative may also sign the certification.
Reference level diagrams 6, 7 and 8 - Distinguishing Features-If the certifier is unable to certify to breakaway/non-breakaway wall.
enclosure size. location of servicing equipment, area use. wall openings, or unfinished area Feature(s). then list the Feature(s) not
included in the certification under Comments below. The diagram number, Section C. Item 1, must still be entered.
I /Sertity that the information in Sections Band C on this certificate represents my best efforts to interpret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U. S. Code. Section 1001.
C~T1F1ER'S NA\Mf71 ^, < \ LICENSE NUMBER (or Affix Seal)
T\/) N P. dI 1-\ \N p...N ~O \--l \ 0 \ e:,3
TITLE \CCMPANY NAME
~~>() S \l "-""-'1.""_ '\~~"'i <S \l"-"~\ 'j Co -,
\LPtotO (R~N\L\,f'l~'A\\ _SE Q\'"'\Or ~\(.€ I
SIGNATURE P 4/ }.fi y _ DATE PHONE
I~~V/)-~=- ;0" 3 -0 V 9S'2...- '-\ l.\, .- 2S, 0
~. \\,
STATE
ZIP
S'5~,2-
lY\N
Copies should be made of this Certificate for: 1) community official, 2) insurance agenUcompany, and 3) buildIng owner.
COMMENTS: NO le_ \\-0 ~'.7e.. '- \N 20 I'\-E', Y- .' ~(Z{""A- d4.k ~\,V\.\ tAo(>tO -k,
\':;:.
e p-e 6, ~~-\IQ*, 500 vI<.. ,~\ O(.)/.Q p l t\.-; rJ
~f' \J..J I 0 C \ C'l ~ ~""\-. I -C-\1De \~ ~ \~C,\-~C~ " \'::> ~\O-\
I
~+' 'bf= G ~.. V{<...\ui'2-... ~- "- q~.~.
\c..,
ON
sua
WTni
BASEJ.IEXT
A V
ZONES ZONES
A
l\!ir ZONES .
r Ell~~
:~1~ . ~
:'~;r(:'~l'\ cAE'C~~EI
. f:N~ ,
!t!=:;o.n:f":':f.'::-{.
~'-:-''-t1:'~''-':~:'::_
IAeFL~~~e~ ~ ~
1 t~)!0~ L'\~~.-"'~
.< ~l r' ;i../"()\
It; ~ ~'...:. '/0',:,
R.ClOD
El.EVA nCN
I AEFe.AE1<Cl: I -"WCENT
l...<VEl. aAAOE
OH PILES.
PlEAS. OR COLUIolNS
A V
ZONES Z:::]NES I
IFlEFEFleNCe~ .
LEVEL ~ I REF~~~e I
mf ,': -oC....-.;..' .
1>' ~.. ,,~~
?!~....~~I
""'" \.'..;',:.:...." ::."'".:. ~J~'
;/f~.::::~...'./;;:~.~:r;~iJ;i:n~t;i.~~.::
The diagrams above illustrate the points at which the elevations should be measured in A Zones and V Zones.
_ Elevations for all A Zones should be measured at the top of the reference level floor.
Elevations for all V Zones should be measured at the bottom of the lowest horizontal structural member.
Page 2