Fema Form 086-0-33 - Elevation Certificate - U.s. Department Of Homeland Security (Page 5 of 23) in pdf

ElEvAtion CErtiFiCAtE, page 2

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 (ContinUED)

Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.

Comments

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, or enclosure) is

feet

meters

above or

below the HAG.

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

feet

meters

above or

below the LAG.

E2. For Building Diagrams 6–9 with permanent flood openings provided in Section A Items 8 and/or 9 (see pages 8–9 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 servicing the building is

feet

meters

above or

below the HAG.

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.

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.

G1.

The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, 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.)

G2.

A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or Zone AO.

G3.

The following information (Items G4–G9) 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