2012-05-24 Elevation CertificateU.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008
Federal Emergency Management Agency I Expires March 31, 2012
National Flood Insurance Program Important: Read the instructions on pages 1-9.
SECTION A - PROPERTY INFORMATION For insurance Company Use:
Al. Building Owner's Name Ms. Becky Reynolds Policy Number
A2. Building Street Address (Including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Company NAIC Number
2239 Meadow Drive
City Blair State Ne ZIP Code 68008
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
Larsen Still Meadow - Lot 12
A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.) Residential
A5. Latitude/Longitude: Lat. 41.33107 Long. -96,08526 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.
A7. Building Diagram Number 2
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 800 sq ft
b) No. of permanent flood openings in the crawlspace or b) No. of permanent flood openings in the attached garage
enclosure(s) within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade 0
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
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B4. Map/Panel Number B5. Suffix B6. FIRM Index 87. FIRM Panel B8. Flood B9 Base Flood Elevation(s) (Zone
0167 D Date Effective/Revised Date Zone(s) AO, use base flood depth)
01/06/2012 A 1065.00
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item 89.
❑ FIS Profile ® FIRM ❑ Community Determined ❑ Other (Describe)
B11, Indicate elevation datum used for BFE in Item 89: ❑ NGVD 1929 ® NAVD 1988 ❑ Other (Describe)
B12. Is the building located Ina 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, ARIA, AR/AE,AR/Al -A30, ARIAH, AR/AO. Complete Items C2.a-h
below according to the building diagram specified in Item A7. Use the same datum as the BFE.
Benchmark Utilized NGS BLAIRVertical Datum NAVD 1988
Conversion/Comments
Check the measurement used.
a)
Top of bottom floor (including basement, crawlspace, or enclosure floor) 1057.45
® feet
❑ meters (Puerto Rico only)
b)
Top of the next higher floor
1066.80
® feet
❑ meters (Puerto Rico only)
c)
Bottom of the lowest horizontal structural member (V Zones only)
❑
feet ❑ meters (Puerto Rico only)
d)
Attached garage (top of slab)
1064.74
® feet
❑ meters (Puerto Rico only)
e)
Lowest elevation of machinery or equipment servicing the building
1057.45
® feet
❑ meters (Puerto Rico only)
(Describe type of equipment and location in Comments)
f)
Lowest adjacent (finished) grade next to building (LAG)
1.52
® feet
❑ meters (Puerto Rico only)
g)
Highest adjacent (finished) grade next to building (HAG)
1065.00
® feet
❑ meters (Puerto Rico only)
h)
Lowest adjacent grade at lowest elevation of deck or stairs, including
1064.49
® feet
❑ meters (Puerto Rico only)
structural support
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by WOW certify elevation
information, I certify that the information on this Certificate represents my best efforts to interpret the data available.)
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
licensed land surveyor? ® Yes ❑ No
Certifier's Name Lyle E. Yenglin License Number LS720
Manager
Company Name
Address PO Box 342 City Blair State Ne ZIP Code 68008
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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
2239 Meadow Drive
City BlairState Ne ZIP Code 68008 Company NAIL Number
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 Furnace in the basement.
12
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, crawispace, 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 and G9.
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 -G9) 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
08. Elevation of as -built lowest floor (including basement) of the building: ❑ feet ❑ meters (PR) Datum
G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters (PR) Datum
G10. Community's design flood elevation ❑ feet ❑ meters (PR) Datum
Local Official's Name Title
Community Name Telephone
Signature Date
Comments
Check here if attachments
FGMG Fnrm A1_31 _ Mar 09 Replaces all previous editions