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U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No.1660-0008
<br /> Federal Emergency Management Agency Expires March 31,2012
<br /> National Flood Insurance Program Important: Read the instructions on pages 1-9.
<br /> SECTION A-PROPERTY INFORMATION Foilriiiittrance Comrsarty Use:
<br /> Al. Building Owner's Name Nellie Jaskewycz PoifctrNumber
<br /> A2. Building Street Address(induding Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number
<br /> 395 Lake Shore Drive
<br /> City Edgerton State WI ZiP Code 53534
<br /> A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
<br /> Lot 35,Block 7,Edgerton Beach Park,0512-254-3785-5
<br /> A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.) Residential
<br /> A5, Latitude/Longitude:Lat. N 42d52'10" Long. W 89d01'08" Horizontal Datum: ❑NAD 1927 © NAD 1983
<br /> A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
<br /> A7. Building Diagram Number 2
<br /> A8. For a building with a crawispace or encosure(s): A9. For a building with an attached garage:
<br /> a) Square footage of crawtspace or enclosure(s) 1190 sq ft a) Square footage of attached garage sq ft
<br /> b) No.of permanent flood openings in the c rawtspace or b) No.of permanent flood openings in the attached garage
<br /> enclosure(s)within 1.0 foot above adjacent grade 7 within 1.0 foot above adjacent grade
<br /> c) Total net area of flood openings in A8.b 641 sq in c) Total net area of flood openings in A9.b sq in
<br /> d) Engineered flood openings? 0 Yes ®No d) Engineered flood openings? []Yes El No
<br /> SECTION 8-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
<br /> ! B1.NFIP Community Name&Community Number 82.County Name 83.State
<br /> I Dane County 550077 Dane WI
<br /> 84.Map/Panel Number I 85.Suffix 86.FIRM Index B7.FIRM Panel B8.Flood 89.Base Flood Elevation(s)(Zone
<br /> 55025C0832G {, Date Effective/Revised Date Zone(s) AO,use base flood depth)
<br /> I
<br /> June 17,2003 January 2,2009 AE 784
<br /> 810. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 89.
<br /> ❑FIS Profile ©FIRM Community Determined ❑Other(Describe)
<br /> B11. Indicate elevation datum used for BFE in Item B9: ❑NGVD 1929 ©NAVD 1988 ❑Other(Describe)
<br /> 812. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? 0 Yes Q No
<br /> Designation Date 0 CBRS 0 OPA
<br /> SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
<br /> C1. Building elevations are based on: ❑Construction Drawings' ❑ Building Under Construction' © Finished Construction
<br /> 'A new Elevation Certificate will be required when construction of the building is complete.
<br /> 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
<br /> below according to the building diagram specified in Item A7. Use the same datum as the BFE.
<br /> Benchmark Utilized Lake Koshkonong Water Surface 777.29,8/6/08 Vertical Datum NGVD29
<br /> Conversion/Comments A conversion of-0.20 is applied in converting from NGVD29 to NAVD88
<br /> *Elevations a-h are NAVD88 Check the measurement used.
<br /> a) Top of bottom floor(including basemen crawlspace, r enclosure floor) Gravel=782.4 E feet ❑meters(Puerto Rico only)
<br /> b) Top of the next higher floor 787,7 X feet ❑meters(Puerto Rico only)
<br /> c) Bottom of the lowest horizontal structural member(V Zones only) N/A _0 feet 0 meters(Puerto Rico only)
<br /> d) Attached garage(top of slab) N/A _Q feet ❑meters(Puerto Rico only)
<br /> e) Lowest elevation of machinery or equipment servicing the building 784,8 O feet []meters(Puerto Rico only)
<br /> (Describe type of equipment and location in Comments)
<br /> f) Lowest adjacent(finished)grade next to building(LAG) 784,7 © feet 0 meters(Puerto Rico only)
<br /> g) Highest adjacent(finished)grade next to building(HAG) 785,2 ©feet [J meters(Puerto Rico only)
<br /> h) Lowest adjacent grade at lowest elevation of deck or stairs,including N/A _0 feet 0 meters(Puerto Rico only)
<br /> structural support
<br /> SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION o t 1.11 1 ti,
<br /> This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation % r.G N eo t Z.. f
<br /> information. t certify that the information on this Certificate represents my best efforts to interpret the data available. \ ,
<br /> 1 understand that any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001. .. Y
<br /> ©Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a"-tl, :' [t�,is r
<br /> licensed land surveyor? ❑Yes © No ' "' Y-r -°
<br /> Certifier's Name License Number - t l-• Y
<br /> Aaron Falkosky E-40083 c-4� U$3 :�""
<br /> Title Project Engineer Company Name Quam Engineering,LLC ~--e ViA!11 SON �'^
<br /> Address City State ZIP Code ;-�' . 'vV! I'' '*y
<br /> 4893 Larson Beach Road McFarland WI 53558 ,,��r�,., ,a
<br /> Signature Date / Telephone r'ti t� -.-4- 1
<br /> (1 7�I sos 838-775o r/if',f� I ,NN
<br /> FEMA Form 81-31,Mar 09 See reverse side for continuation. Replaatl>pte3v)ous editions
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