Fema Form 086-0-33 - Elevation Certificate - U.s. Department Of Homeland Security (Page 22 of 23) in pdf

FLOODPROOFING CERTIFICATE

U.S. DEPARTMENT OF HOMELAND SECURITY

OMB No. 1660-0008

FEDERAL EMERGENCY MANAGEMENT AGENCY

FOR NON-RESIDENTIAL STRUCTURES

Expiration Date: July 31, 2015

National Flood Insurance Program

The floodproofing of non-residential buildings may be permitted as an alternative to elevating to or above the Base Flood Elevation;

however, a floodproofing design certification is required. This form is to be used for that certification. Floodproofing of a residential building

does not alter a community’s floodplain management elevation requirements or affect the insurance rating unless the community has been

issued an exception by FEMA to allow floodproofed residential basements. The permitting of a floodproofed residential basement requires a

separate certification specifying that the design complies with the local floodplain management ordinance.

BUILDING OWNER’S NAME

FOR INSURANCE COMPANY USE

POLICY NUMBER

STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. Number) OR P.O. ROUTE AND BOX NUMBER

COMPANY NAIC NUMBER

OTHER DESCRIPTION (Lot and Block Numbers, etc.)

CITY

STATE

ZIP CODE

SECTION I – FLOOD INSURANCE RATE MAP (FIRM) INFORMATION

Provide the following from the proper FIRM:

COMMUNITY NUMBER

PANEL NUMBER

SUFFIX

DATE OF FIRM INDEX

FIRM ZONE

BASE FLOOD ELEVATION

(In AO Zones, Use Depth)

Indicate elevation datum used for Base Flood Elevation shown above:

NGVD 1929

NAVD 1988

Other/Source:

SECTION II – FLOODPROOFING INFORMATION (By a Registered Professional Engineer or Architect)

Elevations are based on:

Construction Drawings

Building Under Construction

Finished Construction

Floodproofing Design Elevation Information:

Building is floodproofed to an elevation of

feet (In Puerto Rico only:

meters).

NGVD 1929

NAVD 1988

Other/Source:

(Elevation datum used must be the same as that used for the Base Flood Elevation.)

Height of floodproofing on the building above the lowest adjacent grade is

feet (In Puerto Rico only:

meters).

For Unnumbered A Zones Only:

Highest adjacent (finished) grade next to the building (HAG)

feet (In Puerto Rico only:

meters)

NGVD 1929

NAVD 1988

Other/Source:

(NOTE: For insurance rating purposes, the building’s floodproofed design elevation must be at least 1 foot above the Base Flood Elevation to receive rating credit. If the building

is floodproofed only to the Base Flood Elevation, then the building’s insurance rating will result in a higher premium.)

SECTION III – CERTIFICATION (By a Registered Professional Engineer or Architect)

Non-Residential Floodproofed Construction Certification:

I certify that, based upon development and/or review of structural design, specifications, and plans for construction, the design and methods of construction

are in accordance with accepted standards of practice for meeting the following provisions:

The structure, together with attendant utilities and sanitary facilities, is watertight to the floodproofed design elevation indicated above, with

walls that are substantially impermeable to the passage of water.

All structural components are capable of resisting hydrostatic and hydrodynamic flood forces, including the effects of buoyancy, and anticipated

debris impact forces.

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.

CERTIFIER’S NAME

LICENSE NUMBER (or Affix Seal)

TITLE

COMPANY NAME

ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE

DATE

PHONE