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�r.�•r,.... . ..� .. ....,.�, rays� IMPORTANT:In these spaces,copy the corresponding information from Section A. Building Street Address(including Apt., Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. 825 Willow Drive ... =`- City Orono State MN ZIP Code 55331 `A SECTION D—SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED) Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner. Comments Signature Date SECTION E—BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE) For Zones AO and A(without BFE),complete Items E1—E5.If the Certificate is intended to support a LOMA or LOMR-F request,complete Sections A,B, and C.For Items E1—E4,use natural grade,if available.Check the measurement used.In Puerto Rico only,enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade(HAG)and the lowest adjacent grade(LAG). a)Top of bottom floor(including basement,crawlspace,or enclosure)is ❑feet ❑meters ❑above or❑below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is ❑feet ❑meters ❑above or❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor (elevation C2.b in the diagrams)of the building is ❑feet ❑meters ❑above or ❑below the HAG. E3. Attached garage(top of slab)is ❑feet Elmeters Elabove or E]below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is ❑feet ❑meters ❑above or❑below the HAG. E5. Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑Yes ❑ No ❑ Unknown.The local official must certify this information in Section G. SECTION F—PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property owner or owner's authorized representative who completes Sections A,B,and E for Zone A(without a FEMA-issued or community-issued BFE) or Zone AO must sign here.The statements in Sections A,B,and E are correct to the best of my knowledge. Property Owner's or Owner's Authorized Representative's Name David Pemberton Address 150 Broadway Ave.S. City Wayzata State MN ZIP Code 55391 Signature Date 4/16/2013 Telephone 952-476-6000 Comments ❑Check here if attachments. SECTION G—COMMUNITY INFORMATION(OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),and G of this Elevation Certificate.Complete the applicable item(s)and sign below.Check the measurement used in Items G8—G10.In Puerto Rico only,enter meters. G1.❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2.❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone AO. G3.❑ The following information(Items G4—G10)is provided for community floodplain management purposes. G4.Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for: ❑New Construction ❑Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building: ❑feet ❑meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters Datum G10.Community's design flood elevation: ❑feet ❑meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑Check here if attachments. FEMA Form 086-0-33 (7/12) Replaces all previous editions.