Elevation Certificate Template - Douglas County Page 7
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7Douglas County, Oregon
ELEVATION CERTIFICATE, page 6
FLOODPLAIN BUILDING SITE DIAGRAM
(To be completed by an Oregon Licensed Surveyor or Engineer)
PROPERTY I.D. NO. R ____________________
WORK SHEET NO.___________________
TOWNSHIP____________ RANGE ___________ SEC. ___________ SUB SEC. __________ TAX LOT NO. _____________
INFORMATION NEEDED ON DIAGRAM
1. Approximate property lines (show dimensions).
2. Permanent land marks (roads, streams, rivers).
3. Distances from landmarks to building site.
4. Put stakes at building site (one flagged stake in
middle of the site is sufficient).
5. Temporary bench mark established at 100 year
flood elevation.
6. Location of floodway on site.
PART ONE PRE-CONSTRUCTION
100 YEAR BASE
BM NO:
BM
BM
FLOOD ELEVATION:
ELEVATION:
LOCATION:
Elevation datum NAVD 88
TBM
TBM
TBM
ELEVATION:
LOCATION:
DESCRIPTION:
FEDERAL
Yes
FEDERAL
Yes
MEAN
EXTREME
HIGH
LOW
HAZARD
HAZARD
HAZARD
100 YEAR
FLOODWAY
FLOODWAY
VELOCITY:
No
No
BUILDING SITE
FIRM MAP PANEL:
Residential: MINIMUM REQUIRED FLOOR HEIGHT FROM
ELEVATION:
GROUND TO BE 1 FOOT ABOVE BFE:
Manufactured Home: MINIMUM REQUIRED HEIGHT SO BOTTOM
OF LONGITUDINAL CHASSIS FRAME BEAM TO BE AT BFE
Insurance Implication: Construction or placement of structures
Non-residential:
elevated less than 1' above BFE may result in increased
MINIMAL FLOOR HEIGHT FROM GROUND TO BFE
premium rates for flood insurance, and such construction below
Exempt non-residential:
the BFE increases risks to life and property.
MINIMAL FLOODPROOFING HEIGHT FROM GROUND TO BFE
I certify as an Oregon Registered Professional Engineer or Surveyor that the above information is true and accurate.
SIGNATURE_________________________________________________ DATE _____________________________
PART TWO POST-CONSTRUCTION (Part One must also be completed on this form)
The building at the property location described above has the
NAVD 88
The reference level is based on actual
lowest floor (including basement, if any) at an elevation of:
construction.
or has been floodproofed in accordance with the Floodplain
NAVD 88
Yes
No
Ordinance to an elevation of:
I certify as an Oregon Registered Professional Engineer or Surveyor that the above information is true and accurate.
SIGNATURE_________________________________________________ DATE _____________________________
Form 5/18/2016
Edition
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