04-991-005IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use: ;
iUILDIN STREET ADDRESS (Including Apt., Unit, Suite, and/or ekig. No.) OR P.O. ROUTE AND BOX N0, Policy Number
5885 SOUTHWEST 73RD STREET i "'
CITY STATE TIP CODE Company NAIC Number
MIAMI / FL 33143
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
❑ Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)
For Zone AO and Zone A (without BFE), complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR -F,
Section C must be completed.
E1. Building Diagram Number _(Select the building diagram most similar to the building for which this certificate is being completed — see pages 6 and 7. If no diagram accurately
represents the building, provide a sketch or photograph.)
rrrr•
E2. The top of the bottom floor (including basement or enclosure) of the building is ^ ft,(m) _ in.(cm) ❑ above or ❑ below (check one) the highest adjacent grade. (Use •
natural grade, if available). • `
� • rr•• rrr•r
E3, For Building Diagrams 6-6 with openings (see page 7), the next higher floor or elevated floor (elevation b) of the building is ^ ft.(m) �inf ahae the highest•?ijacent r r
grade. Complete items C3.h and C31 on front of form. • • • • • • • • • •
E4. The top of the platform of machinery and/or equipment servicing the building is , _ ft.(m) _in.(cm) ❑ above or ❑ below (check one) the high2st adjacent grade. (Use `
natural grade, if available). • • r • • • • • • • •
E5. For Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplairi wmmagement ordinance? ' r
❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G. • ` ` • ` ` ` • ` •
r •
SECTION F -PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION V
--
The property owner or owner's authorized representative who completes Sections A, B, C (Items C3.h and C3.i only), and E for Zone A (with�bt a FEZ1A4ssued or community- .. • .
issued BFE) or Zone AO must sign here, The statements in Sections A, b, Q and E are correct to the best of my knowtedgt. r • • ` A •
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME . "r `. . ` ` • • y • ` ` •
• . rrrr •. •
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,
G1. ❑ The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, engineer, or architect who is authorized by state
or local law to certiFji`Zlevation information. (Indicate the source and date of the elevation data in the Comments area below.)
G2. ❑ A community off I romp e`.cd S&tion E for a building located in Zone A (without a FEMA- issued or community- issued BFE) or Zone A0.
G3. ❑ The"f Who inf6rmaiiori (ItemSG4 -G9) is provided for community floodplain management purposes.
G4. PERMIT NUMBER ti,'� : ' G . DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMRLIANCEIOCCURANCY ISSUED
G7. This penit has been issued foe`❑ New Construction ❑ Substantial Improvement
G8. Elevation of as -built lowest floor (including i'4sement) of the building is: _ ft.(m) , r; f;�.�f�.r Datum:
G9. BFE or (in Zone AO) dept o�flc�dinp �t thr building site is: ft.(m) w �, , , Datum:
LOCAL OFFICIAL'S NAME.. ~ -'` TITLE ` ; - ` : -' • - '" a °. =
COMMUNITY NAME — - - - - TELEPHONE ._Z "
SIGNATURE DATE ;. �,; u •�" : ';��
COMMENTS _ ��•�
Check here if attachments
FEMA Form d1- 31,'January 2003 Replaces all previous editions