1. Benchmark/Reference Mark Information; the elevations cited herein are based on the following described benchmark (BM): _______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
BM elevation is in: [ ] Sea Level Datum; [ ] assumed datum with BM equal to elevation _______________
2. Structure: a. Elevation of first floor:
Required By
Ordinance
Actual
As-Built
=_____________-_____________ b. Basement elevation: c. Lowest adjacent grade:
3. Sewer: d. Highest adjacent grade: a. Top of septic or holding tank: b. Bottom of drainfield, trench or bed:
4. Low point of access/road:
5. Compacted fill elevation around building:
6. Top of well casing:
=_____________-_____________
=_____________-_____________
=_____________-_____________
=_____________-_____________
=_____________-_____________
=_____________-_____________
=_____________-_____________
=_____________-_____________
7. Elevation to which structure is flood proofed: =_____________-_____________
- CERTIFICATION -
I, __________________________________, hereby certify that, to the best of my knowledge, information and
(print or type name) belief, the subject structure is constructed in accordance with the elevations stated immediately above (items 2 through 7).
Signature:________________________________________________ Date:________________
Registration No. (*):________________________________________
*(Only necessary if local ordinance requires certification by registered professional engineer or registered surveyor)
I, __________________________________, hereby certify that I am a registered [ ] engineer or [ ] architect,
(print or type name) and that, to the best of my knowledge, information and belief, the subject structure is constructed in accordance with the approved plans and specifications which accompanied the above referenced Zoning Application and/or
Zoning Permit and the subject structure meets the criteria and standards for [ ] FP1, [ ] FP2, [ ] FP3, [ ] FP4 flood proofing as well as all local ordinances and the State Building Code where applicable.
Signature:________________________________________________ Date:________________
Registration No.:__________________________________________