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IMPORTANT: ln these apaces, copy tho correspondlng lnformatlon from $actlon A,FOR INSURANCE COMPANY USE <br />Bulldlng Street Address {lncludlng Apt.. Unlt, Sulte, and/or Bldg. No.) or P,O. Route and Box No. <br />3002 Dapple GrayWay <br />Pollcy Number: <br />City Slate <br />Washlngton <br />ZIP Code <br />98926Ellensburg <br />Company NAIC Number <br />sEcTloN G - coMMuNtTy |NFoRMAT|ON (OPT|ONAL) <br />The local offlclal who ls authorlzed by law or ordlnance to adminlster the community's floodplain managemenl ordinance can complele <br />Sections A, B, C (or E), and G of thls Elevation Cerliflcate. Complete the appllcable item(s) and slgn betow. Check the measulement <br />used in ltems G8-G10. ln Puerto Rico only, enter meters, <br />Gl. I The lnlonnation ln Sectlon C was taken from other documentatlon that has been slgned and sealed by a llcensed suryeyor, <br />englneer, or architect who ie authorlzed by law to certiff elevation information, (lndicate the source arid date of the elevillon <br />dala in the Comments area below.) <br />c2. I A community official completed Seclion E for a building located ln Zone A (without a FEMA.issued or community.issued BFE) <br />or Zone AO. <br />GO, I The followlng lnformatlon (ltems G4-G10) ls provlded for communlg floodplaln management purposes, <br />G4, Permit Number G5, Date Permit lssued G6, Dale Cerlificate of <br />Compllance/Occupanoy lssued <br />G7. This permlt has been issued for: fl t'tew Consiruction f] Substantial lmprovement <br />G8. Elevatlon of as-bullt lowesl floor (lncludlng basement) <br />of the building: <br />G9. BFE or (ln Zone AO) deplh of floodlng at the bulldlng site: <br />G10. Gommunity's desigrr llood elevation: <br />I feet f] meters Datum <br />flfeet ! meters Detum <br />I feet fJmeters Datum <br />Local Ofilclal's Name Tltle <br />Communlty Nam€Telephone <br />Slgnature Date <br />Commsnta (lncludlng type of equlpmont and locallon, per G2(e), if applicable) <br />fJ Checf here lf atlachments. <br />ELEVATION CERTIFICATE OMB No. 1660-0008 <br />Expiration Date: November 3O, 2A22 <br />FEMA Form 086-0-33 (12119)Replaces all previous edltions.Form Page 4 of 6