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L FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.e.No.3W-M
NATIONAL FLOOD INSURANCE PROGRAM eorn July 31.2W
ELEVATION CERTIFICATE
Important. Read the instructions on pages 1 '7•
.� ......
SECTION A-PROPERTY OWNER INFORMATION A
BUILDING OWNER'S NAME
IiRICENisnbet`". E :eEE
•••Y.::::�::i:::X:.....:.:.:...:::.:: aT::::
BUt ING STREET ADDRESS(Including ,Unit.Suite,andfor Bldg.No.)OR P.O.ROUTE AND BOX N0. 01!!A!! `I
................ .. .
p Q Lf lV G- ZIP CODE
CITY fL f
So o-A
PR ERTY DESCRIPTION(Lot and Bioek Nur^tkrs,Tax Parcel Numt»r,Legal Oeseriptkrn,etc.)
U L I L ! etc. Use Comments section If } �®
BUILDING USE e.g.,ResidWIWI,Nor esidee>tisl,Addition.AecessaY,
�)
HORIZONTAL DATUM: SOURCE: (J GPS(Type}:
LATtTUDE/LONGRUDE(OPTIONAL) NAD 1f?Z7 IJ NAD tg83 USGS C
lued Mep u Other------
( '. •-p• or SWAWW U
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B3.STATE
61.NFtP COMMUNITY NAME 8 COMMUNITY NUMBER BZ COUNTY N t
z n n
IRM PANELfla.FL000 ne AO,use depot d Ioedrq)
B4.MAP AND PANEL B5.SUFFIX �•FIRM
INDEX EFFECT FtvE/REVISED DATE ZONE(S)
Q
NUMBER
f ZD 1 ICC3 :57 entered In B9.
B10. Indicate the source of the Base Flood Elevation(BFE)•dda or base flood d Other
( )
u FIS Profile FIRM U CommunttY Determined NAVD 1Qgg LJ Other(Describe):
B11. indicate the elevation datum used for the BFE in BQ: NGVD B or Otherwise Protected Area(OPA)4 JJ Yes Ll Na
B12. is the building located in a Coastal Barrier Resources ys ( RS)sres
Designation Date: SECTION C-BUILDING ELEVATION INFORMATION(SURVEY ......
REQUIRED) intshed Cornttudior►
Building Under Construction'
C1.Building elevations are based on: uConstrudion Drawings JJ `
•A new Elevation Certificate will be required when construction of the building is complete.
G2 Building Diagram Number (Baled the building diagram most sirrftr to the building for which Oft Certificate Is being complrrted-see
pages 6 and 7. ff no diagram accurately represents the building, provide a sketch or photograph.)
C3. Elevations—Zones AI-A30,AE, AM,A(with BFE),VE,V1-V30,V(with BFE),
,AR ARIA,AR/AE,AR/A1,A30,AR/AH,ARIAO
t
ed, If the daturb Is
Complete items C3a4 below according to the building diagram
specified In BF�ow field meaatum
surements essuurements datum conversion
the datum used for the BFE in Section B, convert ttte datum t to document the datum cortverslon.
calcutation. Use the space provided or the Comments area of Section D or Section G,as appropriate,
Datum Conversion/Commentss r on the FIRM? LJ Yes No
Elev •on reference mark used Does the elevation reference An
mark used_> rPea
Top of bottom floor(including basement or enclosure)
❑ b)•Top of next higher floor ----
❑ C)-:Bottom of lowest horizontal structural member(V zones only) ®ft(m)
❑ d)Attached garage(top of stab)
❑ e)Lowest elevation of machinery and/or equipment R(m) E�-
servicing the building IL(m) `O-�
❑ Lowest adjacent grade(LAG) ..•7< fL(m)
❑ g)Highest adjacent grade(HAG)
❑ h)No. of permanent openings(flood vents)within 1 It.above adjacent grade sq� )
cm
Cli)Total area of all permanent openings(flood vents)in C3h
SECTION D-SURVEYOR.ENGINEER,OR ARCHITECT CERTIFICATION elevation infonitation
This certification is to be signed and sealed by a land surveyor, engineer, or Archited authorized by law to certify
l certify that the information in Sections A, 8, and C an this Certificate represents my best efforts to interpret the data avar7abb.
001.
i understand that any false statement a be nishable b fine orim •sonment urrduCENSE NUMBER Section
CERTiFIER'S NAME D f�iV T!—��G f� COMPANY NAME t,/d l ilE2S�� �u�J&51y1V('A
TITLE i 3 -Ar7— STATE T�L, ZIP CODE
ADDRESS �t7Z N ,p�ZI�.FDTZ CITY 1be']V lL1TZ1 TELEPHONE (� O
SIGNATURE
FEMA Form 81-3 AUG 9g SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREI/iOU3 EDiT10N8
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