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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 For Insurance Company Use:
<br /> Al. Building Owner's Name D. Hudyma, R.J. Ribnek Rev. Lvg.Trust, R. Ribnek Policy Number
<br /> A2. Building Street Address(including Apt., Unit,Suite,and/or Bldg. No.)or P.O. Route and Box No. Company NAIC Number
<br /> 1 394 Lake Shore Dr.
<br /> City Edgerton State WI ZIP Code 53534
<br /> A3. Property Description(Lot and Block Numbers,Tax Parcel Number, Legal Description,etc.)
<br /> Lots 3 and 4,Block 2, Edgerton Beach Park;PIN 002/0512-254-2283-4; NW1/4 Sec.25,T5N,R12E,Town of Albion, Dane Co.,WI
<br /> A4. Building Use(e.g., Residential, Non-Residential,Addition,Accessory,etc.)Residential
<br /> A5. Latitude/Longitude: Lat.42.8690 Long. -89.0183 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 crawlspace or enclosure(s): A9. For a building with an attached garage:
<br /> a) Square footage of crawlspace or enclosure(s) 680 sq ft a) Square footage of attached garage sq ft
<br /> b) No of permanent flood openings in the crawlspace or b) No. of permanent flood openings in the attached garage
<br /> enclosure(s)within 1.0 foot above adjacent grade 8 within 1.0 foot above adjacent grade
<br /> c) Total net area of flood openings in A8.b 696 sq in c) Total net area of flood openings in A9.b sq in
<br /> d) Engineered flood openings? ❑ Yes ❑ No d) Engineered flood openings? ❑ Yes ❑ No
<br /> SECTION B -FLOOD INSURANCE RATE MAP(FIRM) INFORMATION
<br /> B1. NFIP Community Name&Community Number B2.County Name B3. State
<br /> Dane County 550077 Dane WI
<br /> B4. Map/Panel Number B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9. Base Flood Elevation(s)(Zone
<br /> 55025C0832 G Date Effective/Revised Date Zone(s) AO,use base flood depth)
<br /> January 02, 2009 January 02,2009 AE 784.0
<br /> B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9.
<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 /> B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes ® No
<br /> Designation Date ❑ CBRS ❑ OPA
<br /> SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
<br /> Cl. 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 Manhole Rim Vertical Datum 780.26
<br /> Conversion/Comments
<br /> C4j Ava.. Check the measurement used.
<br /> a) Top of bottom floor(including basement,crawlspace,or enclosure flo• 781.0 ®feet ❑meters(Puerto Rico only)
<br /> b) Top of the next higher floor ®feet
<br /> _ ❑meters(Puerto Rico only)
<br /> c) Bottom of the lowest horizontal structural member(V Zones only) ❑feet ❑ meters(Puerto Rico only)
<br /> d) Attached garage(top of slab) ❑feet
<br /> ❑meters(Puerto Rico only)
<br /> e) Lowest elevation of machinery or equipment servicing the building ❑feet ❑ meters(Puerto Rico only)
<br /> (Describe type of equipment and location in Comments)
<br /> f) Lowest adjacent(finished)grade next to building(LAG) 784.9 ®feet ❑ meters(Puerto Rico only)
<br /> g) Highest adjacent(finished)grade next to building(HAG) 785.0 ®feet ❑meters(Puerto Rico only)
<br /> h) Lowest adjacent grade at lowest elevation of deck or stairs, including ®feet ❑meters(Puerto Rico only)
<br /> structural support
<br /> SECTION D -SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
<br /> This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation 4ti.�l��+=MasN,r
<br /> information. /certify that the information on this Certificate represents my best efforts to interpret the data available.! ,4,1 �CO��. -/10.,°�d
<br /> understand that any false statement maybe punishable by fine or imprisonment under 18 U.S. Code, Section 1001.E .7,.,%,,,s
<br /> '�' ! °""" ,
<br /> Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a �`'�+ `�'� ■•~~'`. r`'
<br /> licensed land surveyor? ❑ Yes ® No GLEN L.
<br /> \
<br /> 1.Certifier's Name Glen L. Northrop a, ' NORTHROP %
<br /> P License Number S-982 e : IA,
<br /> S9132
<br /> Title Surveyor Company Name ABEX Survey Company r •• MADISON. :��
<br /> • .��; WISCONSIN •:•-••
<br /> Address P.O. Box 369 City Cambridge State WI ZIP Code 53523 rti ',..t...wig.
<br /> Signature Date Telephone (608)423-3331 4f:
<br /> //-2to -2aid �Ay* ��,,0
<br /> FEMA Form 81-31, Mar 09 See reverse side for continuation. Replaces all previous editions
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