HomeMy WebLinkAboutCertificate of Elevation
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
a.M.B. No. 3067-0077
Expires July 31,2002
Important: Read the instructions on pages 1 - 7.
SECTION A - PROPERTY OWNER INFORMATION
For Insurance Company Use:
BUILDING OWNER'S NAME
Dennis & RAmona Johnson
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
14530 Pine Road
CITY STATE
Prior Lake MN
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
Lot 5, Block 1 North Shore Crest
BUILDING USE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use Comments section if necessary.)
Residential
LATITUDE/LONGITUDE (OPTIONAL) HORIZONTAL DATUM:
( #if - ##' - ##.#!f' or ##.###f#r) I_I NAD 1927 I_I NAD 1983
SOURCE: I_I GPS (Type):
I_I USGS Quad Map 1X-IOther. As surned
SECTION B. FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER
Prior Lake 270432
B2. COUNTY NAME
Scott County
B3.STATE
Minnesota
84. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX , B7. FIRM PANEL 88. FLOOD B9. BASE FLOOD ELEVATION(S) I
NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO, use depth of flooding)
270432-0002 C 9/29/78 , 11/19/97 AE 909.0
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
LI FIS Profile Us'1 FIRM LI Community Determined LI Other (Describe):
B 11. Indicate the elevation datum used for the BFE in B9: 0-1 NGVD 1929 LI NA VD 1988 LI Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? LI Yes ili-I No
Designation Date:
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: LIConstruction Drawings. LIBuilding Under Construction. 1~-1Finished Construction
. A new Elevation Certificate will be required when construction of the building is complete. .
C2. 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.)
C3. Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARiA, ARiAE, AR/A1-A30, ARJAH, ARiAO
Complete Items C3a-i below according to the building diagram specified in Item C2. State the datum used. If the datum is different from
the datum used for the SFE in Section S, 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
Elevation reference mark used Does the elevation reference mark used appear on the FIRM? I_I Yes I_I No
o a) Top of bottom floor (including basement or enclosure) 910. ~ ft.(m) iO
o b) Top of next higher floor 912 .2- ft.(m) c?J
o c) Bottom of lowest horizontal structural member (V zones only) . _ ft.(m) 1 ~
o d) Attached garage (top of slab) 912 . 2... ft.(m) E-g
o e) Lowest elevation of machinery and/or equipment ~ ~
servicing the building 912 . 2 ft.(m) E-E
o f) Lowest adjacent grade (LAG) 909 ..JL ft.(m) ~~
",Ul
o g) Highest adjacent grade (HAG) 914 .2 ft.(m) ~
o h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade-o ~
o i) Total area of all permanent openings (flood vents) in C3h 0 sq. in. (sq. em)
SECTION D. SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
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 information in Sections A, B, and 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.
CEHTlFIER'S NAME LICENSE NUMBER
John C. Larson 19828
TITLESurve COMPANY NAME Pioneer Engineering, P.A.
CITY STATE ZIP CODE
Mendota Rei hts MN 55120
DATE I CJ ~ 20 ,- t:J 0 TELEPHONE (65 1) 681-19 14
SEE REVERSE SIDE FOR CONTINUATION
REPLACES ALL PREVIOUS EDITIONS
FEMA Fo
IMPORTANT: In these spaces, copy the corresponding Information from Section A.
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
14530 Pine Road
CITY
For Insurance Company Use:
Prior Lake
STATE ZIP CODE
MN 55372
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agenUcompany, and (3) building owner.
COMMENTS
L I Check here if attachments
SECTION E _ BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)
For Zone AO and Zone A (without BFE), complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting
information 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 endosure) of the building is I-LI ft.(m) LLlin.(cm) I_I above or LI below
(check one) the highest adjacent grade.
E3. For Building 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) L-I_lin.(cm) above the highest adjacent grade.
E4. For Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's
floodplain management ordinance? LI Yes I_I No' LI Unknown. The local official must certify this information in Section G.
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A (without a FEMA-issued or
community-issued BFE) or Zone AO must sign here.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS
CITY
STATE
ZIP CODE
SIGNATURE
DATE
. TELEPHONE
COMMENTS
L-I Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain 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. LI The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor,
engineer, or architect who is authorized by state or local law to certify elevation-information. (Indicate the source and date of the
elevation data in the Comments area below.)
G2. I_I A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or
Zone AO.
G3. L-1 The following information (Items G4-G9) is provided for community floodplain management purposes.
, G4. PERMIT NUMBER G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
I ISSUED
G7. This permit has been issued for: LI New Construction LI Substantial Improvement
G8. Elevation of as-built lowest floor (induding basement) of the building is:
G9. BFE or (in Zone AO) depth of flooding at the building site is:
LOCAL OFFICIAL'S NAME
. _ ft.(m) Datum:
. _ ft.(m) Datum: ____
TITLE
COMMUNITY NAME
TELEPHONE
SIGNATURE
DATE
COMMENTS
FEMA Form 81-31, AUG 99
I _I Check here if attachments
REPLACES ALL PREVIOUS EDITIONS