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ELEVATION CERTIFICATE <br />OMB No. 1660-0008 <br />Expiration Date: November 30, 2022 <br />IMPORTANT: In these spaces, copy the corresponding information from Section A. <br />FOR INSURANCE COMPANY USE <br />Building Street Address (including Apt., knit, Suite, and/or Bldg. No,) or P.O. Route and Box No. <br />Policy Number. <br />490 HERON FARM LANE <br />City State ZIP Code <br />Company NAIC Number <br />ELLENSBURG Washington 9$926 <br />SECTION G — COMMUNITY INFORMATION (OPTIONAL) <br />The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete <br />Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement <br />used in Items G8—G10. In Puerto Rico only, enter meters. <br />G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, <br />engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation <br />data in the Comments area below.) <br />G2 ❑ A community official completed Section E for a building located in Zone A (without a FEMA4sued or community -issued BFE) <br />or Zone AO. <br />G3. ❑ The following Information (Items G4—G10) is provided for community floodplain management purposes. <br />G4. Permit Number <br />G5. Date Permit Issued <br />G6. Date Certificate of <br />CompliancelOccupancy Issued <br />G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement <br />G8. Elevation of as -built lowest floor (including basement) ❑feet F] meters <br />of the building: Datum <br />Gg. SFE or (in Zone AO) depth of flooding at the building site: ❑ feet 0 meters Datum <br />G10. Community's design flood elevation: ❑ feet ❑ meters Datum <br />Local Official's Name Title <br />Community Name Telephone <br />Signature Date <br />Comments (including type of equipment and location, per C2(e), if applicable) <br />[1 Check here if attachments_ <br />FEMA Form 086-0-33 (12119) Replaces all previous editions. Form Page 4 of 6 <br />