Elevatio Certificate - 504 S 10th St.U.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE
FEDERAL. EMERGENCY MANAGEMENT AGENCY
Marionol 17oodfnsurance Program Important: Read the instructions on pages 1-9.
SECTION A — PROPERTY INFORMATION
OMB No. 1660-0008
Expiration Date: July 31, 2015
FOR INSURANCE COMPANY USE
Al. Building Owner's Name Chris Jensen Policy Number:
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Company NAIC Number:
504 South 10"' Street.
City Blair
State NE ZIP Code 68008
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
Tax Lot 63 Part of the Southwest 1/4 of the Southeast 1/4 of Sec. 12 T18 N R11E
A4. Building Use (e,g., Residential, Non -Residential, Addition, Accessory, etc.) Non -Residential
A5. Latitude/Longitude: Lat. 41-32-21 Long. 96-07-34 Horizontal Datum: ❑ NAD 1927 ® NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
AT 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) sq ft a) Square footage of attached garage sq ft
b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage
or enclosure(s) within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade
c) Total net area of flood openings in A8.b sq in c) Total net area of flood openings in A9.b sq in
d) Engineered flood openings? ❑ Yes ❑ No d) Engineered flood openings? ❑ Yes ❑ No
SECTION B — FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP Community Name &Community Number 82. County Name B3. State
Blair, City of 310228 Washington Nebraska
B4. Map/Panel Number
B5. Suffix
B6. FIRM Index Date
B7. FIRM Panel
B8. Flood
B9. Base Flood Elevation(s) (Zone
31177CO167D
D
Designation Date: ❑ CBRS ❑ OPA
Effective/Revised Date
Zone(s)
AO, use base flood depth)
Cl. Building elevations are based on: ® Construction Drawings* ❑ Building Under Construction* ❑ Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
01/06/2012
AE
1066.30'
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9.
❑ FIS Profile ® FIRM ❑ Community Determined ❑ Other/Source:
B11. Indicate elevation datum used for BFE in Item 139: ❑ NGVD 1929 ® NAVD 1988 ❑ Other/Source:
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?
❑ Yes ® No
Designation Date: ❑ CBRS ❑ OPA
SECTION C — BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
Cl. Building elevations are based on: ® Construction Drawings* ❑ Building Under Construction* ❑ Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations — Zones Al—A30, AE, AH, A (with BFE), VE, V1—V30, V (with BFE), AR, AR/A, AR/AE, AR/Al—A30, AR/AH, AR/AO. Complete Items C2.a—h
below according to the building diagram specified in Item AT In Puerto Rico only, enter meters.
Benchmark Utilized: MKO091 Vertical Datum: 1094.05'
Indicate elevation datum used for the elevations in items a) through h) below. ❑ NGVD 1929 ® NAVD 1988 ❑ 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) ❑ feet
❑ meters
b) Top of the next higher floor ❑ feet
❑ meters
c) Bottom of the lowest horizontal structural member (V Zones only) ❑ feet
❑ meters
d) Attached garage (top of slab) ❑ feet
❑ meters
e) Lowest elevation of machinery or equipment servicing the building ❑ feet
❑ meters
(Describe type of equipment and location in Comments)
f) Lowest adjacent (finished) grade next to building (LAG) 1069.54 ® feet
❑ meters
g) Highest adjacent (finished) grade next to building (HAG) 1069.97 ® feet
❑ meters
h) Lowest adjacent grade at lowest elevation of deck or stairs, including structural support ❑ feet
❑ meters
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.
R A
I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.�i800
+s®6®0 `L
171 Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a
®����sr,�F®,
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❑ Check here if attachments. licensed land surveyor? ® Yes ❑ No
LS -634
Certifier's Name Joel Jacobsen License Number 634
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410
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Title Prof. Land Surveyor Company Name R.W. Engineering & Surveying, Inc.
Address 6225 N'� 1h Cir City Omaha State NE ZIP Code 68134
Signatur ` Date Telephone 402-573-2205
FEMA Form 086-0-33 (7/12) See reverse side for continuation. Replaces all previous editions.
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:
504 South 101" Street
City Blair State NE ZIP Code 68008 Company NAIC Number:
SECTION D — SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of thislevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
Comments HAG'and'LAG elevation. given on this certificate are the lowest and highest elevation of the ground of the area where structure is to be
- Mbnaturree Date
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.
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, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the HAG.
b) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the LAG.
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 ❑ feet ❑ 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 ❑ feet ❑ meters ❑ above or ❑ 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? ❑ Yes ❑ No ® 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'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)
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 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. ❑ 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. ❑ The following information (Items G4—G10) is provided for community floodplain management purposes.
G4. Permit Number G5. Date 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) of the building: ❑ feet ❑ meters Datum
G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters Datum
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 (7/12) Replaces all previous editions.
Federal Emergency Management Agency
Washington, D.C. 20472
TND 5
March 25, 2014 Case No.: 14-07-1337A
216-A
We have received your request that the Federal Emergency Management Agency determine if the property identified below
is located within an identified Special Flood Hazard Area on the applicable National Flood Insurance Program map.
SECTION 12, T18N, R11E -- 524 SOUTH 10TH STREET
We are reviewing your submitted data and will contact you if additional information is required to process your request. If
additional information is not required, we will issue a final letter of determination within 30-60 days. Inquiries concerning the
status of your request should be made by calling the FEMA Map Assistance Center toll free at (877)-336-2627
(877 -FEMA MAP) or by letter addressed to the Federal Emergency Management Agency, LOMC Clearinghouse, 847
South Pickett Street, Alexandria, VA 22304-4605.` Please be assured we will do our best to respond to all;ingpiries in a
timely manner. },
Federal Emergency Management Agency
Washington, D.C. 20472
MT -RA -EM (Baker) 0302
Official Business
Mr. Chris Jensen
524 South 10th Street
Blair, NE 68008
Federal Emergency Management Agency
Washington, D.C. 20472
Ig1Nn s�o�
April 28, 2014
Mr. Chris Jensen IN REPLY REFER TO:
Jensen Lames Solutions CASE NO: 14-07-1337A
524 South 10th Street COMMUNITY: CITY OF BLAIR, WASHINGTON COUNTY,
Blair, NE 68008 NEBRASKA
COMM—UNITY NO: 310228
216 -AD
RE: SECTION 12, T18N, RI IE — 524 SOUTH 10TH STREET - - -
Dear Mr. Jensen:
This is in response to your request for a Letter of Map Revision based on Fill for the property referenced
above.
The Federal Emergency Management Agency (FEMA) uses detailed application/certification forms for
revision requests or amendments to the National Flood Insurance Program (NFIP) maps. The forms provide
step-by-step instructions for requesters to follow, and are comprehensive, ensuring that the requestors'
submissions are complete and more logically structured. Therefore, we can complete our review more
quickly and at lower cost to the NFIP. While completing the forms may seem burdensome, the advantages
to requestors outweigh any inconvenience.
The following forms or supporting data, which were omitted from your previous submittal, must be
provided:
Please provide pre,and post fill topography: The topography must be certified by a registered
professional engineer or licensed land surveyor.
Please note that if all of the required items are not submitted within 40 days from the date of the first Request
for Additional Data letter that was sent on 3/28/2014, any subsequent request will be treated as an original
submittal .and will be subject to all submittal procedures.
When you write to us concerning your request, please include the case number referenced above in your
letter. All required items for your request are to be either uploaded through the Online LOMC tool, for
requests initiated online, or mailed to the LOMC Clearinghouse, 847 South Pickett Street, Alexandria, VA
22304-4605, for requests initiated through the mail.
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U.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
NaWnal-FleadInsurance Program important: Read the instructions on pages 1-9.
SECTION A - PROPERTY INFORMATION
Al. Building Owner's Name Chris
OMB No. 1660-0008
Expiration Date: July 31, 2015
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. ICompany N -my NUn]4er
504 South l dh Street.
City Blair State NE ZIP Code 68008
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
Tax Lot 63 Part of the Southwest 1/4 of the Southeast 1/4 of Sec. 12 T18 N R11 E
A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.) Non -Residential
A5. Latitude/Longitude: Lat. 41-32-21 Long. 96-07-34 Horizontal Datum: ❑ NAD 1927 E 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 1 B
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) sq ft a) Square footage of attached garage sq ft
b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage
or enclosure(s) within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade
c) Total net area of flood openings in A8.b sq in c) Total net area of flood openings in A9.b sq in
d) Engineered flood openings? ❑ Yes ❑ No d) Engineered flood openings? ❑ Yes ❑ No
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP Community Name & Community NumberI B2. County Name I B3. State
Blair, City of 310228 Washington Nebraska
B4. Map/Panel Number
B5. Suffix
B6. FIRM Index Date
B7. FIRM Panel
Date
B8. Flood
Zone(s)
B9. Base Flood Elevation(s) (Zone
AO, use base flood depth)
31177CO167
D
❑ feet
Effective/Revised
01/06/2012
AE
1066.30'
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9.
❑ FIS Profile E FIRM ❑ Community Determined ❑ Other/Source:
B11. Indicate elevation datum used for BFE in Item 139: ❑ NGVD 1929 E NAVD 1988 ❑ Other/Source:
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑ Yes E No
Designation Date: ❑ CBRS ❑ OPA
SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
Cl. Building elevations are based on: E Construction Drawings* ❑ Building Under Construction* E Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations - Zones Al -A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, ARAE, 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.
Benchmark Utilized: MKO091 Vertical Datum: 1094.05'
Indicate elevation datum used for the elevations in items a) through h) below. ❑ NGVD 1929 E NAVD 1988 ❑ 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)
b) Top of the next higher floor
c) Bottom of the lowest horizontal structural member (V Zones only)
d) Attached garage (top of slab)
e) Lowest elevation of machinery or equipment servicing the building
(Describe type of equipment and location in Comments)
f) Lowest adjacent (finished) grade next to building (LAG)
g) Highest adjacent (finished) grade next to building (HAG)
h) Lowest adjacent grade at lowest elevation of deck or stairs, including structural support
1070.39 E feet
❑ meters
❑ feet
❑ meters
❑ feet
❑ meters
❑ feet
❑ meters
❑ feet
❑ meters
1069.90 E feet
❑ meters
1070.27 E feet
❑ meters
❑ feet
❑ meters
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 fine or imprisonment under 18 U.S. Code, Section 1001.
❑ Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a
❑ Check here if attachments. licensed land surveyor? E Yes ❑ No
Certifier's Name Joel Jacobsen, PLS License Number 634
Title Vice President Company Name R.W. Engineering & Surveying, Inc.
Address 6225Cir
Signature , /
City Omaha
State NE ZIP Code 68134
Date 02-10-2014 Telephone 402-573-2205
PP 1B K A
PLACE'
SEAL
4%^022:
h�� atoeat.a•? • .., ��
FEMA Form 086-0-33 (7/12) See reverse side for continuation. Replaces all previous editions.
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 Numbef.;
504 South 10th Street
City Blair State NE ZIP Code 68008 Company NAIL Numbe{
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.
Cgommen
Date
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.
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, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the HAG.
b) Top of bottom floor (including basement, crawlspace, or enclosure) is I ❑ feet ❑ meters ❑ above or ❑ below the LAG.
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 ❑ feet ❑ 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 ❑ feet ❑ meters ❑ above or ❑ 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? ❑ Yes ❑ No ® 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'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)
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 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. ❑ 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. ❑ The following information (Items G4—G10) is provided for community floodplain management purposes.
G4. Permit Number
G5. Date 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) of the building: ❑ feet ❑ meters Datum
G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters Datum
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 (7/12) Replaces all previous editions.
ELEVATION CERTIFICATE, page 3 Building Photographs
See Instructions for Item A6.
IMPORTANT: In these spaces, copy the corresponding information from Section A. r•um"
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. PoUcy Number.;
504 South 10th Street
City Blair State NE ZIP Code 68008 Company NAIC 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.
East face of building looking to the south.
FEMA Form 086-0-33 (7/12) Replaces all previous editions.
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." 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 (7/12) Replaces all previous editions.