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<br /> • , OMB No. 1660-0008
<br /> J.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 166h 00 8 I
<br /> 'ederal Emergency Management Agency
<br /> Iational Flood Insurance Program Important: Read the instructions on pages 1-9.
<br /> #? ' > >> >
<br /> SECTION A-PROPERTY INFORMATION .........
<br /> Al. Building Owner's Name Eddy Rosengren »:<;:::::.;:.;:;;.;;:.>:.:
<br /> :.1:.'.`.'1\'.\\'':?`�`�������� '::11.'.':11`...\',%:1..>;::;;::.:. •:..•.,..•
<br /> dd
<br /> rasa
<br /> ncl
<br /> udin Apt.,
<br /> Unit Suite and/or Bldg.No.)or P.O.Route and
<br /> Box No. :> !})t N d `>:::>>::> s '>>
<br /> t Address
<br /> A2.
<br /> Building' Str
<br /> ee (including
<br /> 83 Main St.
<br /> City Edgerton State WI ZIP Code 53534
<br /> A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
<br /> Lots 1,2&3,Block 1,Hickory Hills Estate,Section 25,T6N,R12E,Tn of Albion,Dane Co.,WI PIN 002/0512-254-5501-3
<br /> A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Residential
<br /> A5. Latitude/Longitude:Lat.42.865635 Long.-89.020012 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 /> t flame:A8. For a building with a crawlspace or enclosure(s): A9. For a building with anligye
<br /> a) Square footage of crawlspace or enclosure(s) ]360 sq ft a) Square footage of attached 06501r' • Q sq ft
<br /> b) No.of permanent flood openings in the crawlspace or b) No.of permanent flood openings in the altaclliti garage
<br /> within 1.0 foot a acent grade 0
<br /> enclosure(s)within foot above adjacent grade 1 c Total net area t p sill lA9.b Q sq in
<br /> c) Total net area of flood od openings in A8.b sq in d) Engineered flood opening?+1 ❑ Yes ❑ No
<br /> d) Engineered flood openings? ❑ Yes EI No
<br /> SECTION B-FLOOD INSURANCE RATE MAP(FIRM)If IRNION�
<br /> B1.NFIP Community Name&Community Number I B2.County Name
<br /> I Dane Co.550077 Dane Co WI ,
<br /> B9.Base Flood Elevation(s)(Zone
<br /> B4.Map/Panel Number B5.Suffix B6.FIRM Index B7.FIRM Panel B8.Flood AO,use base flood depth)
<br /> 0832 G Date Effective/Revised Date Z AE 5) 784.0
<br /> 1-2-09 1-2-09
<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 ionccorddn Zones Al A30,iA AE,H,A(with hoB E), Item V1-V30,V the same BFE),AR,AR/A, B/AE,AR/A1-A30,AR/AH,AR/AO. Complete Items C2.a-h
<br /> Benchmark Utilized Manhole Rim Vertical Datum 783.65
<br /> Conversion/Comments Benchmark datum 783.88 NGVD29 Datum converted to 783.65 Der FEMA VERT ON:elevment bedw are NGVD88.
<br /> Check 0 feet ❑meters(Puerto Rico only)
<br /> b) Top of the next higher floor
<br /> a) Top of bottom floor(including basement,crawlspace,or enclosure fl..i 788.7� ®feet 0 meters(Puerto Rico only)
<br /> ❑feet ❑meters(Puerto Rico only)
<br /> c) Bottom of the lowest horizontal structural member(V Zones only) ❑feet 0 meters(Puerto Rico only)
<br /> d) Attached garage(top of slab)
<br /> ❑feet ❑meters(Puerto Rico only)
<br /> e) Lowest elevation of machinery or equipment servicing the building
<br /> (Describe type of equipment and location in Comments) L¢ ®feet ❑meters(Puerto Rico only)
<br /> f) Lowest adjacent(finished)grade next to building(LAG) 4 meters(Puerto Rico only)
<br /> g) Highest adjacent(finished)grade next to building(HAG) 254.5 0 feet ❑
<br /> h) Lowest adjacent grade at lowest elevation of deck or stairs,including 784.5 0 feet ❑meters(Puerto Rico only)
<br /> structural support
<br /> SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION `Io,aeal;dl,f,
<br /> This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation ,�'%°5� Ns����i
<br /> information. I certify that the information on this Certificate represents my best efforts to interpret the data available.) F
<br /> understand that any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001.0 �a- %�,.•r"'..•.«"'�,,I A elw
<br /> Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a o �, G L R
<br /> licensed land surveyor? 0 Yes 0 No ' f NOSR; P
<br /> License Number S-982 0 t E : s',
<br /> Certifier's Name Glen L.Northrop = MADISON, :� �.
<br /> Title Surveyor Company Name ABEX Survey Company ��.y WISCONSIN •.e .°
<br /> R �
<br /> State WI ZIP Code 53523 iAA / $'
<br /> City Cambridge ~• .'�' �'
<br /> Address P.O.Box 369 •by«•..'•N�/ '4
<br /> i Date Telephone (608)423 3331 ��A6� •S U;2 ,40
<br /> Signature /� � // � oa4*,LCOtt-
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