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FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077
NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 2005
ELEVATION CERTI~IGATE
Important: Read the Instructions on pages 1 - 7.
SECTION A -PROPERTY OWNER INFORMATION For)dsurinae Ca~)1anyVRa
BUILDING OWNER'S NAME r Policy Wum}~s;f '
eog -~ J.afk.~. S ~ ~ K
BUILDING STREET ADDRES cludinq Apt., U 1, Smle, a d/or I g. No.) OR P.U. ROUTE AND BOX NO, aGacalp;aYRA~C Nua±trar ` ;
~ 8 V s ~~~-ZIP CODE ~ ~•;r:
arY srATE,ma g53-t'~
R;ot~ ~ eta.
PROPERTY DESCRIPTION (Lot end 8 o k Numbers, YaxyP~arcel Number, Legal De:rcriplion, ) ~~n
' 2. O\ ne ~L ~.~
a: m nlNr; rJSE la.a. Resldenbal, on-resitlenhal, A dlUon, Accessory, etc Us a :ommants area, If necessary.) ~nwr 1 ~ a ~ ° y~ a
'UDEAONGITUDE (OPTIONAL) HORIZONTAL DATUM SOURCE: I-I GPS (Type):
_ #p' • p#.#N° or fpJ,#k##11°) -I NAD 1927 I_, NAD 1963 LJ USGS Ouad Map IJ Other ~-
O
84. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX or. r:rcm rn,.r.,. --~
NUMBER DATE EFFECTIVE/RE VISED DATE ZONEIS) (ZoAO~ oo in
ooo'L ~ \\-1°1- °I-- 11-1q R" l X 'll
B10. Indicate the source of the Base Flood Elevation (BFE) tlata or base Flood depth entered in 89.
J_I FIS Profile j_I FIRM { l.rGrommunity Detennlned ~ I_I Other (Describe): _
Bt t. Indicate the elevation datum used for the BFE in 89: ~ r~'I~GVD 1929 ~_( NAVD 1988 I~I Other (Descdbe):
Bt2. Is the building located in a Coastal Barrier Resources System (CBRS) e,rea or Otherwise Protected Area (OPA)? L_I Yes L- o
Designation Date:
SECTION C -BUILDING ELEVATION INFCRMA nun ta~r<vo r Rw.~,^~~r
finished Construction
C1. Building elevations are based on: LlConstruMion Drawings' ~~13uilding Under Construction' )^
'A new Elevation Certificate will be required when construction of the bu Iding is complete.
C2. Building Diagram Number 3 (Select the building diagram most simil:v to the building for which this certificate Is being completed -see
pages 6 and 7. If no diagram accuratety represents the building, provide a sketch or photograph.)
C3. Elevations -Zones At•A30, AE, AH, A (with BFE), VE, Vt-V30, V (w'dh I1FE), AR, ARIA, AR/AE, ARIAi-A30, AR1AH, AR/AO
Complete Items C3.a-i below according to the building diagram specifies in Item C2. State the datum used. If the daturtl is different from
lha datum used for lha BFE in Seeion B, convert the datum to that used for the BFE. Show field measurements antl datum conversion
calculation. Use the space provided or the.Comments area of Section D or Sectbn G, as appropriate, to document the tlatum conversion.
Datum ConversionlComments ear on the FIRMS I~I Yes L-- °
Elevation reference mark used Does the eleva lion reference mark used app
U a) Top of bottom floor (including basement or enclosure) ^--.- ~ 2
b) Top of neM higher floor _.__ tL(m)
J c) Bottom of lowest horizontal structural member (V zones only) = ql~ : ~ fl (m) w P
d) Attached garage (lop of slab)
U e) Lowest elevation of machinery andlor equipment ) - B (m) o
servicing the building (Describe in a Comments area. ~ E
1, f) Lowest adjacent (finished) grade (I.AG) _-~~-' Lam' - ft'(m) s y .
a g) Highest adjacent (finished) grade (HAG) _~~ ~ O fl.(m)
J h) No. of permanent openings (flood vents) within 1 fl. above adjacent grads
O I) Total area of all permanent openings (Bond vents) in C3.h _ sq. in. (sq. cm) -
D-
OR
This certification is to be signed and sealed by a land surveyor, engineer, or
1 certify that the information in Sections A, B, and C on this certillcate repren
iitect authorized by law to certify elevation information.
my best e/torfs to interpret me data available.
t under f8 U. S. Code, Section 1001.
I See reverse side for contihualian. Replaces all
81J1, January 2003