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ELEVATION CERTIFICATE <br />OMB No.1000-0008 <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., Unit, Suile, andfor Bldg. No.) or P.O. Route and Box No. <br />Policy Number: <br />3012 Dapple Gray Way <br />City State ZIP Code <br />Company NAIC Number <br />Ellensburg Washington 98920 <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 oan 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 FEMA-lesued or community -issued BFE) <br />or Zone AO. <br />G3. ❑ The following information (Rome G4-1310) Is provided for community floodplaln management purposes. <br />G4. Permit Number <br />05. Date Permit Issued <br />G8, Date Certificate of <br />Cornpilanoo/Occupancy Issued <br />G7. This permit has been Issued for. ❑u New Construction ❑ Substantial Improvement <br />G8. Elevation of as -built lowest floor (including basement) of the building: _ _ - - ©feet ❑ meters Datum <br />G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters Datum <br />G10. Communily'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 />❑ Check here if attachments. <br />FEMA Form 086-0-33 (12119) Replaces all previous editions. Form Page 4 of 6 <br />