Elevation Certificate - 157 S Industrial Park DrDEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
ELEVATION CERTIFICATE
IMPORTANT: FOLLOW THE INSTRUCTIONS ON PAGES 9-16
OMB Control Number. 1660-0008
Expira0on: 11/3012018
Copy all pages of this Elevation Certificate and all attachments for (1) community official, (2) insurance agenf/company, and (3) building owner.
SECTION A - PROPERTY INFORMATION
FORM INSURANCE COMPANY USE
Al. Building Owners Name
Policy Number.
ROBERT BOLIVIA
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and
Company NAIC
Box No.
Number.
157 INDUSTRIAL
City BLAIR State NE Zip Code 68008
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
LOT 8 ERIKSEN SUB, BLAIR NEBRASKA
A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.)NON-RESIDENTIAL
A5. Latitude/Longitude: Lat. 4132 35.16 Long.96 06 09.39 Horizontal Datum: C NAD 1927 (: 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 1A
A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage:
a) Square footage of crawlspace or enclosure(s)NA sq ft a) Square footage of attached garage NA sq ft
b) Number of permanent flood openings in the NA b) Number of permanent flood openings
crawlspace or enclosure(s) within 1.0 foot in the attached garage within 1.0 foot NA
above adjacent grade above adjacent grade
c) Total net area of flood openings in AB.b NA sq in c) Total net area of flood openings in A9.b NA sq in
d) Engineered flood openings? C Yes (*- No d) Engineered flood openings? C Yes (: No
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP Community Name & Community Number
B2. County Name
B3. State NE
BLAIR, CITY OF
WASHINGTON
134. Map/Panel Number
B5, Suffix
B6. FIRM Index Date
B7. FIRM Panel Effective/
B8. Flood Zone(s)
B9. Base Flood Elevation(s)
31177C0186D
D
Revised Date
AE
(Zone AO, use base flood
JANUARY6,2012
JANUARY 6, 2012
depth
1008.20
Bt O. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item 69:
C FIS Profile C: FIRM C Community Determined C Other/Source:
811. Indicate elevation datum used for BFE in Item B9: C NGVD 1929 C* NAVD 1988 C OthedSource:
B12. Is the building located Ina Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? (-Yes No
Designation Date: C CBRS C OPA
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
Cl. Building elevations are based on: C Construction Drawings* C Building Under Construction* (a Finished Construction
C2. Elevations - Zones Al - A30, AE, AH, A (with BFE), VE, V1 - V30, V (with BFE), AR, ARIA, AR/AE, AR/A1 - A30, AR/AH, AR/AO.
Complete Items C2.a -h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.
A new Elevation Certificate will be required when construction of the building is complete.
Benchmark Utilized: G234 RESET Vertical Datum: 1133.80
Indicate elevation datum used for the elevations in items a) through h) below. C NGVD 1929 (: NAVD 1988
C Other/Source:
Datum used for building elevations must be the same as that used for the BFE. Check the measurement used.
a) Top of bottom floor (including basement, crawlspace, or enclosure floor) 1010.41 - (: feet (- meters
b) Top of the next higher floor 1010.41 - [: feet C meters
c) Bottom of the lowest horizontal structural member (V Zones only) - C feet C meters
d) Attached garage (top of slab) 1010.41 - feet (- meters
e) Lowest elevation of machinery or equipment servicing the building
1010.41 feet C meters
- (:
(Describe type of equipment and location in Comments)
f) Lowest adjacent (finished) grade next to building (LAG) 1009.77 - r feet (- meters
g) Highest adjacent (finished) grade next to building (HAG) 1009.93 t: feet C meters
h) Lowest adjacent grade at lowest elevation of deck or stairs, including
structural support 1010.41 - C: feet C meters
FEMA Form 086.0-33 (7115) Replaces all previous editions. Page 3 of 15
ELEVATION CERTIFICATE
OMB Control Number: 1660-0008
Expiration: 1 113 0/2 01 8
157 INDUSTRIAL BLAIR NE 68008
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This 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 rine or imprisonment under 18 U.S. Code, Section 1001.
Were latitude and longitude in Section AA st ;
® Check here if attachments. provided by a licensed land surveyor?
(e Yes C No cN G Fp
Certifier's Name License Number 8
RANDELL R RECTOR NE LS -742 LS -742
Title Company Name �� O
LAND SURVEYOR PRECISION SURVEYING & CONSULTING r'1�SI t
Address City State Zip Code
936 GRANT ST BLAIR NE 68008
Signature Date Telephone
11-7-2017 +1(402)278-1679
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
Comments (including type of equipment and location , per C2(e), if applicable)"
SEE ATTACHED PHOTOS
Signature /� Date 11-7-2017
SECTION 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.
Et. 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, c rawlspace, _ C feet C meters ❑ above or ❑ below the HAG.
or enclosure) is
b) Top of bottom floor (Including basement, crawlspace, C feet C meters ❑ above or ❑ below the LAG.
or enclosure) is
E2. For Building Diagrams 6 -9 with permanent flood openings provided in Section A Items 8 and/or 9 (see pages 8 -9 of Instructions), the next
higher floor (elevation C2.b in the diagrams) of the building is - C feet C meters ❑ above or ❑ below the HAG.
E3. Attached garage (top of slab) Is (—feet (—meters ❑ above or ❑ below the HAG.
E4. Top of platform of machinery and /or equipment
servicing the building is C feet (meters ❑ above or ❑ below the NAG.
E6. 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? C Yes C No C 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 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 or Owners Authorized Representative's Name: ROBERT BOLIVIA
Address257 S. 25TH ST. CrtyBLAIR StateNEZIP Code68008
Signature Date Telephone
Comments
❑ Check here if attachments.
FEMA Form 086-0-33 (7/15) Replaces all previous editions. rage 4 OT 10
I
OMB Control Number: 1660-0008
Expiration: 1113012018
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 -
G10. In Puerto Rico only, enter meters.
G1. ❑ The information in Section C was taken from other documentation that has been signed and seated 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 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. E] The following information (Items G4 -G10) is provided for community floodplain management purposes.
G4. Permit Number
G5. Data Permit Issued
G6. Date Certificate of Compliance/Occupancy Issued
G7, This permit has been issued for: (' New Construction ( Substantial Improvement
G8. Elevation of as -built lowest floor (including basement) _
(feet C meters Datum
of the building:
GO. BFE or (in Zone AO) depth of flooding at the building (feat C meters Datum
site:
G10. Community's design flood elevation: (-feet (-meters Datum
Local Official's Name Title
Community Name Telephone
Signature Date
Comments
Check here if attachments.
FEMA Form 086-0-33 (7/15) Replaces all previous editions. Page 5 of 15
BUILDING PHOTOGRAPHS
See instructions for Item A6 OMB Control Number. 1 /30/2008
Expiratlon:ll /3012018
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.
Policy Number.
157 INDUSTRIAL
City BLAIR State NE Zip Code Company NAIC
68008 Number:
If using the Elevation Certificate to obtain NFIP flood insurance, affix at least 2 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." When
applicable, photographs must show the foundation with representative examples of the flood openings or vents, as indicated in Section A8. If
submitting more photographs than will fit on this page, use the Continuation Page.
FEMA Form 086-0-33 (7/15) Replaces all previous editions. rage a Or Io
BUILDING PHOTOGRAPHS
Continuation PaOMB Control Number. 1680-0008
Page Expiration: 11/30/2018
IMPORTANT: In these spaces, copy the corresponding information from Section A. FORM INSURANCE COMPANY USE
Building Street Address (including Apt., Unit,Suite, and/or Bldg. No.) or P.O.Route and Box No.
Policy Number.
157 INDUSTRIAL
City State Zip Code Company NAIC Number.
BLAIR NE 68008
If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date
taken; "Front Mew and "Rear Mew" and, if required, 'Right Side Mew' and "Left Side Mew." When applicable, photographs must show the
foundation with representative examples of the flood openings or vents, as indicated in Section A8.
FEMA Form 086-0-33 (7/15) Replaces all previous editions. Page 7 of 15
DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 1660-0015
COMMUNITY ACKNOWLEDGMENT FORM Expires February 28, 2014
PAPERWORK BURDEN DISCLOSURE NOTICE
ng burden for this data collection is estimated to average 1.38 hours per response. The burden estimate includes the time for reviewing instructions,
sting data sources, gathering and maintaining the needed data, and completing and submitting the form. This collection is required to obtain or retain
Fbenefits,
are not required to respond to this collection of Information unless a valid OMB control number is displayed on this form. Send comments regarding
of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security,
gency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0015). NOTE: Do not send your
completed form to this address.
This form must be completed for requests involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of this request to
remove a property from the SFHA which was previously located within the regulatory floodway (complete Section B).
This form must be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number and the
subject property address must appear in the spaces provided below. Incomplete submissions will result in processing delays. Please refer to the MT -1 instructions
for additional Information about this form.
Community Number: 3 / D..D. g Property Name or Address: 157 S Industrial Park Dr, Blair, NE, 68008
A. REQUESTS INVOLVING THE PLACEMENT OF FILL
As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter of Map
Revision Based on Fill (LOMR-F) or Conditional LOMR-F request. Based upon the community's review, we find the completed or proposed project
meets or is designed to meet all of the community floodplain management requirements, including the requirement that no fill be placed in the
regulatory floodway, and that all necessary Federal, State, and local permits have been, or in the case of a Conditional LOMR-F, will be obtained.
For Conditional LOMB -F requests, the applicant has or will document Endangered Species Act (ESA) compliance to FEMA prior to issuance of the
Conditional LOMR-F determination. For LOMR-F requests, I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved
Independently of FEMA's process. Section 9 of the ESA prohibits anyone from "taking" or harming an endangered species. If an action might harm
an endangered species, a permit is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA.
For actions authorized, funded, or being carried out by Federal or State agencies, documentation from the agency showing its compliance with
Section 7(a)(2) of the ESA will be submitted. in addition, we have determined that the land and any existing or proposed structures to be removed
from the SFHA are or will be reasonably safe from flooding as defined in 44CFR 65.2(c), and that we have available upon request by DHS -FEMA, all
analyses and documentation used to make this determination. For LOMR-F requests, we understand that this request is being forwarded to DHS -
FEMA for a possible map revision.
Community Comments:
N/A
Communit OM ial's Name and Title: (Please Print or Type)
T le hone No.:
rem
NOW (P- Jq
Community Name:
Community fficial's Signature: (required)
Date:
C I IV df' �low, r
B. PROPERTY LOCATED WITHIN THE REGULATORY FLOODWAY
As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this request for a
LOMA. We understand that this request is being forwarded to DHS -FEMA to determine if this property has been inadvertently included in the
regulatory floodway. We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway. We find
that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements.
Community Comments:
N/A
Community Official's Name and Title: (Please Print or Type)
Telephone No.:
Community Name:
5
Community Official's Signature (required):
Date:
d
DHS - FEMA Form 086.0-26B, FEB 11 Community Acknowledgment Form MT -1 Form 3 Page 1 of 1
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