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ELEVATION CERTIFICATE FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM NO ROUTE BOX NUMS~R STATE ZiP CODE This form i$ to be completed by a land surveyor, engineer, or architect who Is authorized by state/aw to certify elevation information when the elevation infornlefion for zones A 1-A30. AE, AH, A(with BFE), Vt-V30, VE, and V(with BFE) is required In the case of zone AO, the building official,, the property Jauthorized by local/aw or ordinance to provide floodplain management information may a/so complete this form,, SECTION I BUILDING ELEVATION INFORMATION Using the Flood Insurance Manual or the NFIP Flood Insurance Application--Pad 2 Worksheet, indicate the proper diagram number__ FIRM Zones Al-A30= AE, AH, and A (with BFE), The top of the reference level floor from the selected diagram is at an elevation of_ ,~d-~, c~ feet NGVD (or olher datum-see #5) FIRM Zones V1-V30, VE, and V (with BFE) The bottom of the lowest horizontal structural member of the reference level floor Irom the selected diagram is at an elevation of .......... feet NGVD (or other datum-see #5) FIRM Zone AD The floor used as the reference level from the selected diagram is LUfeet above highest natural grade next to the building (also enter in line 8), This value must be equal to or greater than the AD Zone flood depth number listed below If no flood deplh number is available~ is tile building's lowest floor (or reference level) elevated in accordance with the community's floodplain management ordinances? []Yes []No []Unknown Indicate the elevation datum system used in determining the above reference level elevations:: .r_)~-NGVD []Other (describe on back) Indicate Ihs elevation datum system used on the FIRM for base flood elevations:: ~NGVD [~Other (describe on back) iA TTENTION If tee elevation datum used in measurin the elevations is different than that u~ed on the FIRM, then the elevations provided IS the reference level based on actual construction? ~ Yes ~'No* * A ='No" answer Is only valid if the building does not have the reference level floor in place. Fill in the elevation based on construc- lion drawings and do not complete question fl8 If ='No"' is checked= this certification will be valid only for build~ngs in the course et construction. After construction of the reference level floor is completed, a post-construction elevation certificate will be required for Provide the following measurements using the natural grade next to the building (round to the nearest toot). a The reference level is b, The garage floor (if applicable) is: [_J~ feet [-~above []below (check one) the highest grade,, I I I feet []above []below (check one) the higr~est grade [~feet [~_~above ~']below (check one) the Iowesl grade, I I Ifee~ []above []below (check one) the lowest grade. SECTION II FLOOD INSURANCE RATE MAP INFORMATION Provide the following from the proper FIRM (see Instructions on back-Date of FIRM) and accompanying insurance application:: I' ~0~--U~ F PANEL NO SUFFIX ~,[~:1~'~'~ "tL"~I~M ..... FIRM ZONE BASE FL~O ELEV COMMUNt~ ESlIMATED ~5~ / Elevation re~erencemark used appears on FIRM ~ ~ No ($ee reverse side for detail~,,, SECTION Ill CERTIFICATION fi~i~ certdication ~ to 6~ ~igned by a land surveyor engineer or architect who i~ ~uthbrized by state law to certify elovati~n[ormatiOn When tfie elovatlon tnfornlaflon for zones A I-A30 AE= AH A(with BFE)~ V1.VSO~ VE. and V(with BFE) I$ required In the cass of zone AC),, the buitding official~ the I property owner or the owner's representative c~t~ sign the certification Community official$ who are authorized by local/aw or ordinance to provide I I tho data avaitabte I understand that any false s'tatement may be punishaele by fine or imprisonment under 18 U $. Ccc/e~ Section lOOt LICENSE NUMSER (or Affix S6~t COMPANY NAME DATE PHONE