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CERTIFICATE
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM
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<br />STREET ADDRESS
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<br />POLICY NUMeER
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<br />Th $ form i$ to be completed by a land su~e~r engln~r or archit~t who is authoriz~ by ~tate I~w fo ~i~ elevation information ~en the slaver;on
<br />information for z~e~ A 1.A30, AE, AH. A(wiffi BFE), VI-V30, VE, and V(with BFE) i3 mqui~, In the case of zone AO, the building offictal, the prope~y
<br />[owner Or the Owner $ representer ~ should complete the nfofma ion in Section I and may also ~mplete the ~lfl~tlon, ~mmunity officials who are
<br />[authorized by local law or ordinance to p~v de fl~p a n management nforme ion may al~ ~m~o e this form,
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<br />SECTION I BUILDING ELEVATION INFORMATION
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<br />1. Using the Flood Insurance Manual or the NFIP Flood Insurance Application--Part 2 Worksheet. indicate the proper diagram number__
<br />2, FIRM Zones Al-A30, AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an
<br /> elevation of ~'~/~. ~ feet NGVD. (or other datum-see #5)
<br />3. FIRM Zones V1-V30, VE. and V (with BFE). The bottom o[ [he lowest horizontal structural member of the reference level floor from
<br /> the selected diagram is at an elevation of feet NGVD (or other datum-see #5).
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<br />4. FIRM Zone AO. The floor used as the reference level from the selected diagram is [ I Ifeet above highest natural grade next to
<br /> the building (also enter in llne 8), This value must be equal to or greater than the AO Zone flood depth number listed below. If no
<br /> flood depth number is available, is the bugding's lowest floor (or reference level)' elevated in accordance with the community's
<br /> floodplain management ordinances? E]Yes r~No []Unknown
<br />5. Indicate the elevation datum system used in determining the above ~efereooe level elevations: ~'NGVD [] Other (describe on back)
<br />6. Indicate the elevation datum system used on the FIRM for base flood ele~;ations: E]NGVD [~Other (describe on back)
<br /> (ATTENTION: If the elevation datum used in measuring the elevagons is different'than that u~4~d on the FIRM, then the elevations provided
<br /> must be converted to the datum system used on the FIRM,)
<br /> the reference level based on actual construction? [~Yes ~No*
<br />7.
<br /> Is
<br /> * 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-
<br /> tion drawings and do not complete question #8, If "No" is checked, this certification will be valid only for buildings in the course of
<br /> construction. After construction of the reference level floor is completed, a post-construction elevation certificate will be required for
<br /> continued flood insurance coverage,
<br />8, Provide the following measurements using the natural grade next to the building (round to the nearest foot),
<br /> a, The reference level is: b, The garage floor (if applicable) is:
<br /> LJ_J feet [] above [] below (check one) the highest grade. [ ] ,J feet r-I above I~ below (check one) the highest grade.
<br /> L] Ifeet [-labove E]below (check one) the lowest grade, I I Ifeet ~labove []below (check one) the lowest grade.
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<br />SECTION II FLOOD INSURANCE RATE MAP INFORMATION
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<br />Provide the following from the proper FIRM (see Instructions on back-Date of FIRM) and accompanying insurance application:
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<br /> /[ · Z OR ONEV,,FAVA, *aL
<br />Elevation reference mark used appears on FIRM []Yes E~No (See reverse side for details)
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<br /> SECTION III CERTIFICATION
<br />This certification ia to be signed by a land surveyor, engineer, Or architect Who ia authorized by state/aw to certify eleval~on' i~fo~ma't'~"wh'~'~'"ilg~ .............
<br />elevation information for zon.e..$ A 1.A$0, AE, AH, A(with BFE), VI.V$O, VE, and V(wiffi FIFE) i$ required, In the case of ,Tone AO, the building official, the
<br />Jproperly owner, or the owner s representative can sign the certification. Community officials who are authorized by local law or ordinance to provide
<br />Ill, plain rnanagemept information, may also sign the certification. I certify that the information on this certificate represents my best efforts to interpret
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<br />CEeTIFIER'S NAME
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<br />TITLE Y
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<br />S~GNATUR£
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<br />coMPANY NAME
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<br />CITY STATE
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<br />ZIP
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<br />PHONS
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<br />THIS FORM MAY BE REPRODUCEb.
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<br />FOR OPTIONAL COMMUNIT~ USE: Is the reference level also the lowest floor under the community's floodplain management ordinances?
<br />[~YE$ [~NO If NO the elevation of the lowest floor is feet NGVD.
<br />F~U,* ~:OR~ ~.3~ (,,~s~') 593-117 (6/87)
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