Elevation Certificate Template - Douglas County Page 4
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7ELEVATION CERTIFICATE,
page 3
OMB Control Number: 1660-0008
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 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.
The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer,
G1.
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.)
A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE)
G2.
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)
feet
meters
Datum
.
of the building:
G9. BFE or (in Zone AO) depth of flooding at the
feet
meters
Datum
.
building site:
G10. Community's design flood elevation:
feet
meters
Datum
.
Local Official's Name
Title
Community Name
Telephone
Signature
Date
Comments (including type of equipment and location, per C2(e), if applicable)
Check here if attachments.
FEMA Form 086-0-33 (7/15)
Replaces all previous editions.
Page 5 of 15
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