Fema Form 086-0-33 - Elevation Certificate - U.s. Department Of Homeland Security (Page 4 of 23) in pdf

ElEvAtion CErtiFiCAtE

U.S. DEPARTMENT OF HOMELAND SECURITY

OMB No. 1660-0008

FEDERAL EMERGENCY MANAGEMENT AGENCY

Expiration Date: July 31, 2015

iMPortAnt: Follow the instructions on pages 1–9.

National Flood Insurance Program

SECtion A – ProPErtY inForMAtion

FOR INSURANCE COMPANY USE

A1. Building Owner’s Name

Policy Number:

A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P .O. Route and Box No.

Company NAIC Number:

City

State

ZIP Code

A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)

A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.)

A5. Latitude/Longitude: Lat.

Long.

Horizontal Datum:

NAD 1927

NAD 1983

A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.

A7. Building Diagram Number

A8. For a building with a crawlspace or enclosure(s):

A9. For a building with an attached garage:

a) Square footage of crawlspace or enclosure(s)

sq ft

a) Square footage of attached garage

sq ft

b) No. of permanent flood openings in the crawlspace or

b) Number of permanent flood openings in the attached garage

enclosure(s) within 1.0 foot above adjacent grade

within 1.0 foot above adjacent grade

c) Total net area of flood openings in A8.b

sq in

c) Total net area of flood openings in A9.b

sq in

d) Engineered flood openings?

Yes

d) Engineered flood openings?

Yes

SECtion B – FlooD inSUrAnCE rAtE MAP (FirM) inForMAtion

B1. NFIP Community Name & Community Number

B2. County Name

B3. State

B4. Map/Panel Number

B5. Suffix

B6. FIRM Index Date

B7. FIRM Panel Effective/

B8. Flood Zone(s)

B9. Base Flood Elevation(s) (Zone

Revised Date

AO, use base flood depth)

B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9:

FIS Profile

FIRM

Community Determined

Other/Source:

B11. Indicate elevation datum used for BFE in Item B9:

NGVD 1929

NAVD 1988

Other/Source:

B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?

Yes

Designation Date:

CBRS

OPA

SECtion C – BUilDinG ElEvAtion inForMAtion (SUrvEY rEQUirED)

C1. Building elevations are based on:

Construction Drawings*

Building Under Construction*

Finished Construction

*A new Elevation Certificate will be required when construction of the building is complete.

C2. Elevations – Zones A1–A30, AE, AH, A (with BFE), VE, V1–V30, V (with BFE), AR, AR/A, AR/AE, AR/A1–A30, AR/AH, AR/AO. Complete Items

C2.a–h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.

Benchmark Utilized:

Vertical Datum:

Indicate elevation datum used for the elevations in items a) through h) below.

NGVD 1929

NAVD 1988

Other/Source:

Datum used for building elevations must be the same as that used for the BFE.

Check the measurement used.

a) Top of bottom floor (including basement, crawlspace, or enclosure floor)

feet

meters

b) Top of the next higher floor

feet

meters

c) Bottom of the lowest horizontal structural member (V Zones only)

feet

meters

d) Attached garage (top of slab)

feet

meters

e) Lowest elevation of machinery or equipment servicing the building

feet

meters

(Describe type of equipment and location in Comments)

f) Lowest adjacent (finished) grade next to building (LAG)

feet

meters

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

feet

meters

h) Lowest adjacent grade at lowest elevation of deck or stairs, including

feet

meters

structural support

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.

Check here if comments are provided on back of form.

Were latitude and longitude in Section A provided by a

Check here if attachments.

licensed land surveyor?

Yes

PLACE

Certifier’s Name

License Number

SEAL

Title

Company Name

HERE

Address

City

State

ZIP Code

Signature

Date

Telephone

FEMA Form 086-0-33 (7/12)

See reverse side for continuation.

Replaces all previous editions.

Fema Form 086-0-33 - Elevation Certificate - U.s. Department Of Homeland Security Page 4

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