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IMPORTANT: ln these spaces, copy the correspondlng lntormatlon tfom Secton A.FOR INSURANCE COMPANY USE <br />Building Sireet Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No <br />390 HERON FARM LANE <br />Policy Number: <br />City State <br />Washington <br />ZIP Code <br />98926ELLENSBURG <br />Company NAIC Number <br />sEcnoN G - coMMUNrw TNFoRMAnON (OpnONALl <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 Certiftcate. Gomplete the applicable item{s) and sign below. Check the measurement <br />used in ltems G8-G10. ln Puerto Rico only, enter meters. <br />G1. n The information in Section C was taken from other docunentation trat has been signed <br />engineer, or architect who is authorized by law to certify elevation information. (lndicate <br />data in the Commenb area below.) <br />and sealed by a licensed suNeyor, <br />lhe source and dale of lhe elevation <br />c2. [ ]?";;fffiY ofiicial completed Section E for a building located in Zone A (without a FEMA-issued or comrnunity.issued BFE) <br />63. n The following information (ltems G4-G10) is provided for community fioodplain managemcnt purposes. <br />G4. Permit Number G5. Date Permit lssued G6. Date Cefficate of <br />Compliance/Occupancy lssued <br />G7. This permit has been issued for: ! New Conskuclion I Substantial lmprovement <br />G8. Elevation of as{uilt lowest floor (including basement) <br />of the building: <br />G9. BFE or (in Zone AO) depft of flooding at ths bullding site: <br />G10. Community's design flood elevation: <br />fl feet I meters <br />fl feel fl meters <br />flfeel I meters <br />Dafum <br />Datum <br />Datum <br />Local Ofliciel's Name Title <br />Oommunity Name Telephone <br />Signaturc Datc <br />Commcnts (induding type of equipment and location, per C2(e), il4plicable) <br />! Check here if attachments. <br />ELEVATION CERTIFICATE OMB No. <br />Expiration <br />16604008 <br />Date: Novembet 30,2022 <br />FEMA Form 086-0-33 (12119)Replaces all previous editions.Forn Page 4 of6