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Elevation Certificate - 524 S 10th StU.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CER1 I I A 1 FEDERAL EMERGENCY MANAGEMENT AGENCY Alaflonal h7nacl Insurance Program Important: Read the instructions on pages 1 -9. SECTION A - PROPERTY INFORMA Al. Building Owner's Name Chris Jensen A2. Building Street Address (including Apt., Unit, Suite, and /or Bldg. No.) or P.O. Route and Box No. 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 R11 E OMB No. 1660 -0008 Expiration Date: July 31, 2015 FOR INSURANCE COMPANY USE I Policy Number: Company NAIC Number: 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): a) Square footage of crawlspace or enclosure(s) b) Number of permanent flood openings in the crawlspace or enclosure(s) within 1.0 foot above adjacent grade c) Total net area of flood openings in A8.b d) Engineered flood openings? ❑ Yes ❑ No - - - - -- — SECTION B - FLOOD A9. For a building with an attached garage: sq ft a) Square footage of attached garage sq ft b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade sq in c) Total net area of flood openings in A9.b sq in d) Engineered flood openings? ❑ Yes ❑ No INSURANCE RATE MAP (FIRM) INFORMATION Bl. NAP Community Name & Community Number B2. 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 I D I Effective /Revised Date Zone(s) AO, use base flood depth) 01/06/2012 AE 1066.30' 1310. 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: 1094.0 Indicate elevation datum used for the elevations in items a) through h) below. ❑ NGVD 1929 0 NAVD 1988 ❑ Other /Source: Datum used for building elevations must be the same as that used for the BFE. 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) 0 Lowest adjacent (finished) grade next to building (LAG) g) Highest adjacent (finished) grade next to building (HAG) h) Lowest adj1 acent rade at lowest elevation of deck or stairs includin 9 p structural su port Check the measurement used. El feet El meters ❑ feet El meters ❑ feet El meters F1 feet El meters ❑ feet El meters 1069.54 ® feet 1069.97 ® feet ❑ feet 9 SE CTION D - SU RVEYOR, 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. / 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? ® Yes ❑ No Certifier's Name Joel Jacobsen Title Prof. Land Surveyor / Address 6225 N'89 "' Cir , f ✓ / Signature X) , s - AV FEMA Form 086 -0 -33 (7/12) License Number 634 Company Name R.W, Engineering & Surveying, Inc. City Omaha State NE ZIP Code 68134 Date -' .. /`, Telephone 402 - 573 -2205 See reverse side for continuation. ❑ meters ❑ meters ❑ meters 11 A ge+ /I Replaces all previous editions. LLLVA71ON4LK11� 11-IC,A1L:,Pa,gO2- IMPORTANT: In these spaces, copy the corresponding information from Section A. Building Street Address (including Apt., Unit, Suite, and /or Bldg. No.) or P.O. Route and Box No. 504 South 10 "' Street City Blair State NE ZIP Code 68008 FOR INSURANCE COMPANY USE Policy Number: Company NAIC 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 HAGraileLAG elevation, given on this certifcate are the lowest and highest elevation of the ground of the area where structure is to be constructed,, ', / / I signature / 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 ❑fleet ❑ 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 ® Unknow The local official must certify this information in Section G. SECTION F — PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) C ERTIFICATION 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 rl 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 I G5. Date Permit Issued I 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 G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters G10. Community's design flood elevation: ❑ feet ❑ meters Local Official's Name Title Community Name Telephone Signature Date Comments Datum Datum Datum n Check here if attachments. FEMA Form 086 -0 -33 (7/12) Replaces all previous editions.