Elevation Certificate Template - Douglas County (Page 3 of 7) in pdf

OMB Control Number: 1660-0008

ELEVATION CERTIFICATE,

page 2

Expiration: 11/30/2018

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:

City

State

Zip Code

Company NAIC

Number:

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.

Were latitude and longitude in Section A

provided by a licensed land surveyor?

Check here if attachments.

Yes

Certifier's Name

License Number

PLACE

SEAL

Title

Company Name

HERE

Zip Code

Address

City

State

Signature

Date

Telephone

Copy all pages 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)

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,

above or

below the HAG.

feet

meters

or enclosure) is

b) Top of bottom floor (including basement, crawlspace,

above or

below the LAG.

feet

meters

or enclosure) is

E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9 (see page 8 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

feet

meters

above or

below the HAG.

servicing the building is

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

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 Owner's Authorized Representative's Name

Address

City

State

ZIP Code

Signature

Date

Telephone

Comments

Check here if attachments.

FEMA Form 086-0-33 (7/15)

Replaces all previous editions.

Page 4 of 15

Elevation Certificate Template - Douglas County Page 3

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