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HomeMy WebLinkAbout040105_elevation_certificate_5406wthirdst.pdfFEDERAL. EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077 NATIONAL FLOOD INSURANCE PROGRAM Expires December 31, 200E ELEVATION CERTIFICATE Important: Read the Instructions on pages 1 - 7. SECTION A - PROPERTY OWNER INFORMATION For Insurance Company Use: BUILDING OWNER'S NAME i,) Policy nfurrt6er BUILDING SjREET ADQRESS (inc&ckngyAA, Unit, Suit@,gndtor Bldg. No.) OR P.O, ROUTE AND BOX NO, Company WC Number ( #r - #Y' - ##.#r ar f3#. 1 } I--.J MAD 1927 J_J NAD 1983 """�••" �--+ r , + �-A USGS Quad Map I-J Other SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION 131. NMP COMMUNITY NAME & COMMUNITY NUMBER 82 COUNTY NAME 83. STATE n o CA 84. MAP AND PANEL 85. SUFFIX B6. FIRM INDEX 67. FIRM PANEL 88. FLOOD 09. BASE FLOOD ELEVATION(S) NUMBER s DATE EFFECTIVFIREVISEDDATe "'_ ZONE(S) gone AO, use depth at flooding) �� - BiO-Indkcata the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. J_J RS Profile J FIRM j,,,_J Community Determined J—J Other (Describe): 811. indicate the eievation'datum used for the BFE in B9: J___.J NGVD 1929 J�N NAVD 1988 J_J Other (Describa): B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? I_I Yes L4No Designation Date: SECTION C - BUILDING ELEVATION INF RMATION (SURVEY REQUIRED) C1. Building elevations are based on: Construction Drawings" alBuilding Under Construction' URnished 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 cortfficate is being completed - see pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) C3. Elevations- Zones Al-A30, AE, Ali, A (with BFE), VE, V1430, V (with BFE), AR, ARIA, ARIAE, AWA1 A30, ARIAH, AR/AO Complete Items C3.a-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 BFE in Section B. 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 Convorsion/Comments Elevation reference mark used Does the elevation reference mark used appear o J No C1 a) Top of bottom floor (inctuding basement or enclosure) fL(m) © b) Top of next higher floor +,' � 0 c) Bottom of lowest horizontal structural member (V zones only) . _ ft.(M) ,rs ❑ d) Attached garage (top of slab) ft.(m) 2 i� 4 e) Lowest elevation of machinery and/or equipment Qi servicing the building (Describe in a Comments area.) _ ft.(m) NO- CS7604 0 f) Lowest adjacent (finished) grade (LAG) ft.(m) z • g) Highest adjacent (finished) grade (HAG) ft.(m) � �EXP. O h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade t �� 0 I) Total area of aft permanent openings (flood vents) In C3.h sq. In. (sq. cm) �l� 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, f certify that the information in Sections A, B, and C on this certificate represents my best efforts to Interpret the data available. f Understand thatany false statement may be 2unishable by tine or kn rfsorrment under 18 U.S. Cade, Section 1001. CERTIFIERS NAME r. t 1"a In t\,( f^ I Y-rk LICENSE NUMBER RtllLillhlt=��iTF7FFT6rSrSRCCCrF.,.•b,.f.,..a..� �e..0 c,a�_ �_e.__.,.�_ .. .........-.--------- IMPORTANT: In these spaces, copy the corresponding information from Section A For "urance Company Use: BUILDING §TREET ADDRESS (IndtVin _Apl, Unit,,,SuRe, tndlW§kfq. No.) OR PA. ROUTE AND BOX NO. Pocky Number CITY - I STATE ZIP CODE Company NAIC Number ,4�a > A- CA 9--1a -z' SECTION D - SURVEYOR. ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner. COMMENTS 1-1 Check here it altachments 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 El. through E5, 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.) > 2. The top of the bottom floor (including basement or enclosure) of the building Is j-2�.vj ft. (m) (_ j in. (cm)"/' above or �_J below (check one) the highest adjacent grade. (Use natural grade, if available.) E3. For Building Diagrams " with openings (sea page 7), the next higher floor or elevated floor (elevation b) of the building Is ft. (m) ��Jin. (cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form. E4. The top of the piatform of machinery and/or equipment servicing the building is L-1-1 ft (m) j,_,._�_J in. (am) 1_1 above or L-1 below (check one) the highest adjacent grade. (Use natural grade, if available.) E5. 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? 1_1 Yes 1_1 No 1_{ Unknown, The local official must certlfy 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, C (Items C3.h and C3.1 only), and E forZ,one A (without a FEMA-Issued or community -Issued 5FE) or Zone AO must sign here. The statements In Sections A, B, Q. and E are correct to the best of PROPERTY ADDRESS ATIVE'S NAME 11Ir.7.T.TITy LChecc here if attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by taw 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 hem(s) and sign below. G1. 1-1 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. 1-1 A community official completed Section E for a building located in Zone A (without a F'EMA-issued or community -issued SFE) or Zone AO, G3.1_E The following inforrnabon (items G4-09) Is provided for community floodplaln management purposes. IG4. PERMIT NUNMER G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY J ISSUED G7. This permit has been issued for: i_.,-j New Construction �_' Substantial Improvement G8. Elevation of as -butt lowest floor (including basement) of the building is: —ft. (m) Datum: G9.8FE 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_I Check here if attachments FEMA Form 81-31. January 2003 Replaces all previous editions