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IMPORTANT: In these spaces, copy the corresponding information from Section A. F r Insurance Company Use:
BUILDING STREET ADDRESS (Including Apt_, Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. Policy Number
16285 NW. 39 PLACE
CITY STATE ZIP CODE Company NA1C Number
MIAMI FL 33054
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
❑ Check here if attachments
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 Ell through E4. If the Elevation Certificate is intended for use as supporting information for a COMA or
LOMB-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 _ ft.(m) in.(cm) 0 above or 0 below (check one) the highest adjacent
grade.
=3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is _ ft.(m)
in.(cm) above the highest adjacent grade.
E4. The top of the platform of machinery and/or equipment servicing the building is _ft.(m)_in.(cm) 0 above or 0 below (check one) the highest adjacent
grade,. (Use natural grade, if available).
=5. 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? 0 Yes 0 No 0 Unknown. The local official must certify 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, and E for Zone A (without a FEMA4ssued or
community-issued BFE) or Zone AO must sign here.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATURE DATE TELEPHONE
COMMENTS
Check here if attachments
SECTION G - COMMUNITY INFORMATION (OPTIONAL)
-he local official who is authorized by law or ordinance to administer the communiVs floodplain management ordinance can complete Sections A, B, C (or E),
and G of this Elevation Certificate. t'fomolete the applicable item(s) and sign below.
G1. 0 The information in Section C vas token from other documentation that has been signed and embossed by a licensed surveyor, engineer, or architect who
is authorised by state or local taw to certify elevation information. (indicate the source and date of the elevation data in the Comments area below.)
G2. 0 A-community offic*compls" Ssction E for a building located in Zone A (without a FEMA-issued or community4ssued BFE) or Zone AO.
G3. 0 The following, inforrbation f tems. G4-G9) is provided for community floodplain management purposes.
G4. PERMIT NUMBER JG5. DATE PERMIT ISSUED i 1G6. EADTE CERTIFICATE OF COMPLIANCFJOCCUPANCY
37. This permit has been issued for: 0 New Construction 0 Substantial Improvement
G8. Elevation of as-bull lowest floor (Including basement) of the building is: Datum:
G9. BFE or (in Zone AO) depth of flooding at the building site is: _ fL(m) Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE
COMMENTS
Check here if attachments
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