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IMPORTANT: In these spaces.copvthecorresloondinaInformation from Section A. VFarinsurawCom nvUse: . ]
CRY - `3 - STATE ZIPCODE I CoimpanyNAICNumber _I
Copy both sides of this Elevation Certificatefor(1) cor mun ty official, (2) insurance agenUconpany, and (3) building owner.
SECTION E
Check
ForZone AO and ZoneA (without BFE), complete Items E1 through E4. ff the Elevation Certificate is intended for use as supporting information fora LOMA or LOMR-F,
Section C must be completed.
E1. Building Diagram Number-(Select the building dagram most similartothe building forwhich this certificate is being completed-see pages 6 and 7. If nodiagram accurately
represents the building, provide a sketch or photograph.)
E2 The top of theboffornW(incudingbaseriorenclosure) ofthebuilding is _ft.(m)_in.(cm)❑above or ❑below(checone) the highest adjacent grade. (Use
natural grade, If available).
E3. For Building Diagrams6$with openings (seepage 7),thenext higherflooror elevated floor (elevation b)of the buildingis _ft.(m)_in.(cm)above thehighest adjacent
grade. Complete hems C3,h and C3.1 on front of form.
E4. Thetop of the platform of machinery andraequipmentservicing thebuilding is _fL(m)_in.(am)❑above or ❑below(checone)thehighestadjacentgrade.(Use
natural grade, if available).
E5. ForZone AO only, If no flood depth number is available, is the top of the bottom floor elevated in accordance with the oonmunigls floodplain management ordinance?
❑ Yes ❑ No ❑ Unknown. The local official must certify ft information in Section G.
The property owner or owrWs aulhodmd representative who completes Sections A, B, C (Items C3.h and C3J only), and E for ZoneA (without a FEMA4ssued or communily-
issuedBFE)orZareAOmust sign here, The statements inSechbnsA,QC,andEamcarecttothebestofmylmoWedge.
PROPERTY OWNERS OR OWNERS AUTHORIZED REPRESENTATIVES NAME
ADDRESS CITY STATE ZIPCODE
DATE
❑ Check here if attachments
SECTION G -COMMUNITY INFORMATION (OPTIONAL)
Thek corn d@dal who is authorized bylaw oradnance to administerthe oommuntlys floodplain management ordnance can complete Sections A, B, C (orE), and G of this Elevation
Certificate..CanpleteUieapplicable item(s)andsign below
.
G1. ❑ The infonnaton in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, engineer, or architectwho is authorized by state
or bcdlaiv;dce*elevaficninfotmation. (Indxxtethesource anddate oftheelevation dataintheComments area below.)
G2. ❑ A community offid4ompleted Sedtion Elora building located in ZoneA (vrifhart a FEMA4ssued acanmun*4-issued BFE) orZoneAO.
G3. ❑ Thefdlowing information (ftei G4G9) is provided forcommunity floodplain management purposes.
G7. This permit has been issued for.. ❑NewConshdon ❑Substantiallmprovement
G8. Elevation of as-butt lowestfloor(ndudng basement) of the building is: _ft(m) Datum:
Gg.BFEa(inZoneAO)dephdtoodngatthekwildngsteis: _._fL(m) Datum:_
LOCAL OFFICIAL'S NAME TITLE
COMMUNITYNAME TELEPHONE
SIGNATURE DATE
FEMA Form 81-31, January 2003
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