ࡱ> &(#$%` |bjbj >/C N N N 00013| mr >5 ????BxD\Eppppppp$ythvtp5N JA@BJJp ??'rOOOJ^ ?N ?pOJpOO\g  6N j ?25 bM0%KB|i<hld=r0mri8UwgLUwxjUwN jlF`GOGtdHcFFFpp/O^FFFmrJJJJ $". .  U.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE Federal Emergency Management Agency National Flood Insurance Program Important: Read the instructions on pages 1-8. SECTION A - PROPERTY INFORMATIONFor Insurance Company Use:A1. Building Owners Name  FORMTEXT      Policy NumberA2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.  FORMTEXT      Company NAIC Number City  FORMTEXT       State  FORMTEXT    ZIP Code  FORMTEXT      A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)  FORMTEXT       A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.)  FORMTEXT       A5. Latitude/Longitude: Lat.  FORMTEXT       Long.  FORMTEXT       Horizontal Datum:  FORMCHECKBOX  NAD 1927  FORMCHECKBOX  NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number  FORMTEXT       A8. For a building with a crawl space or enclosure(s), provide a) Square footage of crawl space or enclosure(s)  FORMTEXT       sq ft b) No. of permanent flood openings in the crawl space or enclosure(s) walls within 1.0 foot above adjacent grade  FORMTEXT       c) Total net area of flood openings in A8.b  FORMTEXT       sq in A9. For a building with an attached garage, provide: a) Square footage of attached garage  FORMTEXT       sq ft b) No. of permanent flood openings in the attached garage walls within 1.0 foot above adjacent grade  FORMTEXT       c) Total net area of flood openings in A9.b  FORMTEXT       sq in SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1. NFIP Community Name & Community Number  FORMTEXT      B2. County Name  FORMTEXT      B3. State  FORMTEXT       B4. Map/Panel Number  FORMTEXT      B5. Suffix  FORMTEXT      B6. FIRM Index Date  FORMTEXT      B7. FIRM Panel Effective/Revised Date  FORMTEXT      B8. Flood Zone(s)  FORMTEXT      B9. Base Flood Elevation(s) (Zone AO, use base flood depth)  FORMTEXT      B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9.  FORMCHECKBOX  FIS Profile  FORMCHECKBOX  FIRM  FORMCHECKBOX  Community Determined  FORMCHECKBOX  Other (Describe)  FORMTEXT       B11. Indicate elevation datum used for BFE in Item B9:  FORMCHECKBOX  NGVD 1929  FORMCHECKBOX  NAVD 1988  FORMCHECKBOX  Other (Describe)  FORMTEXT       B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?  FORMCHECKBOX Yes  FORMCHECKBOX No Designation Date  FORMTEXT        FORMCHECKBOX  CBRS  FORMCHECKBOX  OPA SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on:  FORMCHECKBOX  Construction Drawings*  FORMCHECKBOX  Building Under Construction*  FORMCHECKBOX  Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations Zones A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AH, AR/AO. Complete Items C2.a-g below according to the building diagram specified in Item A7. Benchmark Utilized  FORMTEXT       Vertical Datum  FORMTEXT       Conversion/Comments  FORMTEXT       Check the measurement used. a) Top of bottom floor (including basement, crawl space, or enclosure floor)  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) b) Top of the next higher floor  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) c) Bottom of the lowest horizontal structural member (V Zones only)  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) d) Attached garage (top of slab)  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) e) Lowest elevation of machinery or equipment servicing the building  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) (Describe type of equipment in Comments) f) Lowest adjacent (finished) grade (LAG)  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) g) Highest adjacent (finished) grade (HAG)  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (Puerto Rico only) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATIONThis certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the information on this Certificate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.  FORMCHECKBOX  Check here if comments are provided on back of form. Certifier s Name  FORMTEXT       License Number  FORMTEXT       Title  FORMTEXT       Company Name  FORMTEXT      Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT    ZIP Code  FORMTEXT       Signature  FORMTEXT       Date  FORMTEXT       Telephone  FORMTEXT       IMPORTANT: In these spaces, copy the corresponding information from Section A.For Insurance Company Use:Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.  FORMTEXT      Policy NumberCity  FORMTEXT       State  FORMTEXT    ZIP Code  FORMTEXT      Company NAIC NumberSECTION 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  FORMTEXT      Signature  FORMTEXT       Date  FORMTEXT        FORMCHECKBOX  Check here if attachmentsSECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)  For Zones AO and A (without BFE), complete Items E1-E5. If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A, B, and C. For Items E1-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement, crawl space, or enclosure) is  FORMTEXT      . 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FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters  FORMCHECKBOX  above or  FORMCHECKBOX  below the LAG. E2. For Building Diagrams 6-8 with permanent flood openings provided in Section A Items 8 and/or 9 (see page 8 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters  FORMCHECKBOX  above or  FORMCHECKBOX  below the HAG. E3. Attached garage (top of slab) is  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters  FORMCHECKBOX  above or  FORMCHECKBOX  below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters  FORMCHECKBOX  above or  FORMCHECKBOX  below the HAG. E5. 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?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unknown. The local official must certify this information in Section G. SECTION F - PROPERTY OWNER (OR OWNER S REPRESENTATIVE) CERTIFICATIONThe property owner or owner s authorized representative who completes Sections A, B, and E for Zone A (without a FEMA-issued or community-issued BFE) or Zone AO must sign here. The statements in Sections A, B, and E are correct to the best of my knowledge.Property Owner s or Owner s Authorized Representative s Name  FORMTEXT      Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT    ZIP Code  FORMTEXT       Signature  FORMTEXT       Date  FORMTEXT       Telephone  FORMTEXT      Comments  FORMTEXT        FORMCHECKBOX  Check here if attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL)The local official who is authorized by law 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 item(s) and sign below. Check the measurement used in Items G8. and G9. G1.  FORMCHECKBOX  The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2.  FORMCHECKBOX  A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or Zone AO. G3.  FORMCHECKBOX  The following information (Items G4.-G9.) is provided for community floodplain management purposes. G4. Permit Number  FORMTEXT      G5. Date Permit Issued  FORMTEXT      G6. Date Certificate Of Compliance/Occupancy Issued  FORMTEXT      G7. This permit has been issued for:  FORMCHECKBOX  New Construction  FORMCHECKBOX  Substantial Improvement G8. Elevation of as-built lowest floor (including basement) of the building:  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (PR) Datum  FORMTEXT       G9. BFE or (in Zone AO) depth of flooding at the building site:  FORMTEXT      . FORMTEXT        FORMCHECKBOX  feet  FORMCHECKBOX  meters (PR) Datum  FORMTEXT       Local Official s Name  FORMTEXT       Title  FORMTEXT      Community Name  FORMTEXT       Telephone  FORMTEXT      Signature  FORMTEXT       Date  FORMTEXT      Comments  FORMTEXT        FORMCHECKBOX  Check here if attachments Building Photographs See Instructions for Item A6. For Insurance Company Use:Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.  FORMTEXT       Policy NumberCity  FORMTEXT       State  FORMTEXT    ZIP Code  FORMTEXT       Company NAIC Number If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to the instructions for Item A6. Identify all photographs with: date taken;  Front View and  Rear View ; and, if required,  Right Side View and  Left Side View. If submitting more photographs than will fit on this page, use the Continuation Page, following.  Building Photographs Continuation Page For Insurance Company Use:Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.  FORMTEXT       Policy NumberCity  FORMTEXT       State  FORMTEXT    ZIP Code  FORMTEXT       Company NAIC Number If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date taken;  Front View and  Rear View ; and, if required,  Right Side View and  Left Side View.      FEMA Form 81-31, February 2006 See reverse side for continuation. Replaces all previous editions FEMA Form 81-31, January 2003 See reverse side for continuation. Replaces all previous editions FEMA Form 81-31, January 2003 See reverse side for continuation. 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