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FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE Important: Read the Instructions on pages 1 - 7, O.M.B. No. 3067-0077 Expires July 31, 2002 SECTION A • PROPERTY OWNER INFORMATION BUILDING OWNER'S NAME For Insurance Company Policy Number nyUsf &>^TTY BUILDING STREET ADDRESS (Induding Apt., Unit, Suite, and/or Bldg, No.) OR P.O. ROUTE AND BOX NO. 3 A S B u P - V Company NAJC Number CITY STATE IP ZIP CODE S 3 g r / 3 PROPERTY DESCRIPTION (Loland Block Numbers, Tax Parcel Number, Legal Description, etc.] Lot If.; a te u/A uue^'s 3^ /3®P it7h-a/tz> C nrcF wscw BUILDING USE Residential,Non-residenlial,Addition, Accessory, etc, I P £ ^ T 1 A Jse Comments section if necessary.) SOURCE: l_l GPS (Type):. LATITUOEAONGITUOE (OPTIONAL) ( w-mr-m.m' or HORIZONTAL DATUM: I I NAD 1927 NAD 1983 I I USGS Quad Map I I Other. SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 61. NFIP COMMUNITY NAME 4 COMMUNITY NUMBER B2. COUNTY NAME 83. STATE NA06C 2- l DA-H-O 64. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL Bfl. FLOOD B9. BASE FLOOD ELEVATION(S) NUMBER D DATE EFFECTIVE/REVISEDDATE ZONE(S) (Zone AO, use depth of flooding) lU>00 Company NAIC Number SECTION D • SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for community official, Insurance agent/company, and building owner. COMMENTS 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 orLOMR-F, Section C must be completed. E1. Building Diagram Number SZ. (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 ) I I ft.(m) I I!£Iln.(cm) IZCI sbove or I_I below (check one) the highest adjacent grade, E3. For Building Dlaorams 6-8 with openings (see page the next higher floor or elevated floor (elevation b) of the building is I 3j ft.(m) IQ)7 Iln.(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? Yes I_J No I_I 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, •zroHW PRO nER'S Oft OWNER'S AUTHORIZES REPRESENTATIVE'S L...!3v3~ $5 E1T77 ULi-tA&i-s \A//l Lrl I T/ • sv^ 9 ^ 3 ZIP CODE STATE 52><7) Z3Z--903!? T E L E P H O N E — COM, 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 and G of this Elevation Certificate. Complete the applicable ltem(s) and sign below, G1. I I 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-lssued or community-issued BFE) or Zone AO. G3. I_I The following Information (Items G4-G9) Is provided for community floodplain management purposes. G4 PERMIT NUMBER GS, DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLiANCBOCCUPANCY G4 PERMIT NUMBER ISSUED G7. This permit has been issued for: I_I New Construction l_I Substantial Improvement G8. Elevation of as-built lowest floor (Including basement) of the building Is: , ft.(m) Datum: G9. BFE or (in Zone AO) depth of flooding at the building site Is: . ft.(m) Datum: LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS I ( Check here if attachments FFMA Fnrm fl1-.11 AUG 99 RFPI A C.FS Al I PREVIOUS EDITIONS