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L)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 /> 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 - i\-c \,\. �� 0\\-\ 7 N
<br /> A8. For a building with a crawlspace or enclosure(s): /z A9. For a building with an attached garage:
<br /> a) Square footage of crawlspace or enclosure(s) 945 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 4 ,� within 1.0 foot above adjacent grade
<br /> c) Total net area of flood openings in A8.b 324 sq in r rY� c) Total net area of flood openings in A9.b sq in
<br /> d) Engineered flood openings? ❑ Yes ® No ( t'�
<br /> d) Engineered flood openings? ❑ Yes ❑ No
<br /> SECTION B-FLOOD INSURANCE RATE MAP(FIRM) INFORMATION e
<br /> 1 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 A 784.2
<br /> B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9.
<br /> ❑ FIS Profile 4 (FIRM j •A,Community Determined ❑ Other(Describe) I�(j1 4:L1
<br /> 811. Indicate elevation datum used fotlBFE in Item B9: ❑ NGVD 1929 ® NAVD 1988 ❑ Other(Describe) Oa-
<br /> B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes ® No JVST
<br /> Designation Date ❑ CBRS ❑ OPA n(-.). Li
<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 02.a-h
<br /> below according to the building diagram specified in Item A7. Use the same datu.• the BFE.
<br /> Benchmark Utilized Manhole Rim Vertical Datum 780.26
<br /> Conversion/Comments • p (
<br /> • Check the measurement used.
<br /> a) Top of bottom floor(including basement,crawlspace,ore ,•t4" .y.1 • ®feet ❑meters(Puerto Rico only)
<br /> b) Top of the next higher floor 7;,,:r ®feet ❑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) IL . '❑feet ❑meters(Puerto Rico only)
<br /> e) Lowest elevation of machinery or equipment servicing the 1 ❑feet ❑meters(Puerto Rico only)
<br /> (Describe type of equipment and location in Commen
<br /> f) Lowest adjacent(finished)grade next to building(LAG 784.9 ®feet El meters(Puerto Rico only)
<br /> g) Highest adjacent(finished)grade next to building(HA 785.0 El feet ID 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 i111t4aWtr'gre
<br /> This certification is to be signed and sealed by a land surveyor, engineer,or architect authorized by law to certify elevation 43o. GO Iv F
<br /> information. I certify that the information on this Certificate represents my best efforts to interpret the data available.! ��� �.? „ ' E
<br /> understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.E3 4% "••. �;•
<br /> Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a * GLEN L. �\ ♦- t
<br /> licensed land surveyor? ❑ Yes ® No I: NORTHROP
<br /> RP
<br /> Certifier's Name Glen L.Northrop License Number S-982 e.Y! i S•982
<br /> w = MADISON, ' .'
<br /> Title Surveyor a r' •
<br /> t
<br /> Y Company Name ABEX Survey Company �' V�ISCO�JSIN
<br /> *' 4 • o
<br /> Address P.O. Box 369 City Cambridge State WI ZIP Code 53523 ••�A' / o.•N��••�.�•••j"4`,Q4v
<br /> Signature /�/ Date r2 / Telephone (608)423-3331 ?,�C��kf,;};A St�!4'�O
<br /> FEMA Form 81-31, Mar 09 See reverse side for continuation. Replaces all previous editions
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