20141085 Ver 1_401 Application_20141014

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Qresources I water, air, earth
215 Jamestown Park, Suite 100 - Brentwood, TN 37027 0 (615) 373 -8532
October 9, 2014 137493
NC DWR, 401 & Buffer Permitting Unit
512 North Salisbury Street
Raleigh, NC 27604
RE: 401 Wetland Permit Application
Property Across from 14441 Highway 53
Maple Hill, NC 28454
Holly 53 NC, Site Number 280885
To Whom It May Concern:
AquAeTer, Inc. has prepared an application and supporting documents for a 401
Wetland Permit for the proposed construction of a communication tower near Maple Hill, Pender
County, North Carolina on behalf of American Tower Corporation. Since this proposed
communication tower project will affect less than one acre of wetland and less than 150 feet of
stream, this project is considered a minor water quality application. Enclosed are the required
four copies of the application and supporting documents and, also, the $240 fee required for a
minor water quality application.
If you have questions or comments pertaining to this proposal, please contact us by
telephone at (615) 373 -8532, by facsimile at (615) 373 -8512, or by electronic mail at
ncarmean @aquaeter.com.
Sincerely,
AquAeTer, Inc.
Nicholas Carmean
Project Scientist
Enclosure
Pamela Hoover
Technical Director

O�O� W A T E9�G
h r
Q <
Office Use Only.
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
T 2014
0
DENR -WATER RESOURCES
401 & BUFFER PERMITTING
Page 1 of 10
PCN Form — Version 1.4 January 2009
Pre - Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1a.
Type(s) of approval sought from the Corps:
❑X Section 404 Permit ❑ Section 10 Permit
1b.
Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ Yes ❑X No
1d.
Type(s) of approval sought from the DWQ (check all that apply):
❑X 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes ❑X No
For the record only for Corps Permit:
❑ Yes Z No
1f.
Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes ❑X No
1g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
X❑ Yes ❑ No
1h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑X No
2.
Project Information
2a.
Name of project:
Holly 53 NC
2b.
County:
Fender
2c.
Nearest municipality / town:
Maple Hill, NC
2d.
Subdivision name:
n/a
2e.
NCDOT only, T.I.P. or state project no:
n/a
3.
Owner Information
3a.
Name(s) on Recorded Deed:
William Mashburn
3b.
Deed Book and Page No.
DB 598 Page 100
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
Across from 14441 Highway 53
3e.
City, state, zip:
Maple Hill, NC 28454
3f.
Telephone no.:
910 - 934 -2437
nn
3g.
Fax no.:
n/a
3h.
Email address:
n/a
T 2014
0
DENR -WATER RESOURCES
401 & BUFFER PERMITTING
Page 1 of 10
PCN Form — Version 1.4 January 2009

4.
Applicant Information (if different from owner)
4a
Applicant is
❑ Agent ❑X Other; specify Leasee
4b
Name
Richard Rossi
4c
Business name
(if applicable)
American Tower Corporation
4d
Street address
1.0 Presidential Way
4e
City, state, zip
Woburn, MA 01801
4f
Telephone nor
781 - 926 -7187
4g,
Fax no
781- 926 -7011
4h
Email address
Enviro services @americantower corn
5.
Agent/Consultant Information (if applicable)
5a
Name
Nicholas Carmean
5b
Business name
(if applicable)
AquAeTer, Inc
5c
Street address
215 Jamestown Park, Suite 100
5d
City, state, zip
Brentwood 37027
5e
Telephone no
615 - 373 -8532
5f
Fax no -
61,5- 373 -8512
5g, Email address -
ncarmean @aquaeter com
Page,Zof 10

B.
Project Information and Prior Project History
1.
Property Identification
1a 'Property`identification , no '(tax PIN or-parcel ID)
3383 -24- 5222 -000
1b
Site coordinates (m decimal degrees)`
Latitude 34 6613 Longitude -777277-
1c
Property size
66 acres
2.
Surface Waters
2a
Name of nearestbody of water to proposed project
Angola Creek
2b
Water Quality Classification of nearest receiving water
C,Sw
2c
River basin
Cape Fear River Basin
3.
Project Description
3a Describe the existing conditions on the site and th&general land use in the vicinity of the project at'the time of this
application
The site is located primanly'in an agricultural field The proposed access easement crosses a jurisdictional ditch The compound area lies both in the
agricultural field and within a jurisdictional forested wetland It is believed'that,th&site would not require mitigation due,to`the,established agricultural
nature, and the minimal impact to the edge of the forested wetland
3b
List the,total estimated acreage of all existing wetlands on the property 12 3
3c
List the total estimated linear feet of all existing streams (intermittent'and perennial) on the property 761
3d
The
Explain the purpose of the proposed project
proposed project,will provide cellular coverage to an area that currently does not -have sufficient coverage
3e Describe the overall project in detail, including the type of equipment to be used
This project includes the construction of a 310 -foot self - support- communication tower-,,with a 465 -foot by 12 -foot access easement
4.
Jurisdictional Determinations
4a , Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project, (incl Odi n call' nor phases) in the past?
0 Yes ❑ No ❑ Unknown
Comments Jurisdictional wetland and agricultural ditch
4b
If the Corps made the,junsdictional determination, what type
of determination was made
❑ Preliminary El Final
4c
If yes, who delineated the jurisdictional areas?
Name (if known) Kyle Dahl - USAGE
Agency /Consultant Company
Other
4d If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
Preliminary determination was =made on June�5, 2014
5.
Project History
5a
Have permits or certifications been requested or obtained for
this project (including all pr`_ior phases) in the past?
❑ Yes X❑ No ❑ Unknown
5b
If yes, explain in detail according to "help file" instructions
6
Future Project Plans
6a
Is this °a phased project?
❑ `Yes ❑X No
6b
If yes, explain
,Page 3 of 10
PCN Form — Version 1 4 January 2009

C. Proposed Impacts Inventory
'1. Impacts Summary
1a WhichSsectionsawere completed below for your project (check all that apply)
X❑ Wetlands ❑X Streams —tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If,there are wetland impacts proposed on the site, then complete this question for each wetland area impacted
2a
Wetland' impact
number
Permanent (P) or
Temporary
2b
Type of impact
2c
Type.of wetland
2d
Forested
2e
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
_
2f
Area of
impact
(acres)
W1 P
Fill
Unknown
Yes
Corps
0 086
W2 -
Choose,one
Chooseione
Yes /No
W3 -
Choose one
Choose one
Yes/No
W4 -
Choose one
Choose one
Yes /No
W5 -
Choose one
Choose one
Yes /No
W6 -
Choose one
Choose one
Yes /No
2g Total Wetland Impacts:
0 086
2h Comments
3. Stream Impacts
If there are perennial or intermittent,stream impacts (including temporary impacts) proposed on the site, then complete thiss
question for all stream sites impacted
3a
Stream impact
number
Permanent (P) or
Temporary (T)
3b
Type of, impact
3c
Stream name
3d
Perennial (PER) or
intermittent (INT)?
3e
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1 T
Culvert
UT1 to Angola Creek
INT
Corps
3
15
S2 -
Choose one
S3
Choose one
S4 =
Choose one
S5
Choose one
-
S6
Choose one
3h Total stream and tributary impacts
15
31 Comments
Page 4 of 10
PCN Form — Version 1 4 January 2009

4. Open Water 'Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open,water of
the U S then indivii ually list all open water impacts below
4a
Open water
impact number
Permanent (P) or
Temporary
4b
Name of,waterbody
(if applicable)
4c
Type of impact
4d
Waterbody
type
4e
Area of impact (acres)
01
Choose one
Choose
O2
Choose one
Choose
03
Choose one,
Choose
04 -
Choose one
Choose
4f Total open water impacts
4g Comments
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below -,
5a
Pond ID number-
5b
Proposed use or
purpose of pond
5c
Wetland Impacts (acres)
5d
Stream Impacts (feet)
5e
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f Total:
5g Comments
5h Is a dam high hazard permit required?
E] Yes ❑ No If yes, permit ID no
51 Expected pond surface area (acres)
5j' Size of pond watershed (acres)
5k Method of construction
6_ Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below If yes, then, individually list all buffer impacts
below If any impacts require miticiation, then° ou MUST fill out Section D of this form
6a. Project is in,which protected basin ?,
❑ Neuse ❑ Tar - Pamlico ❑ Catawba ❑ Randleman ❑ Other
6b,
Buffer Impact
number—
Permanent (P) or
Temporary
6c
Reason for impact
6d
Stream name
6e
Buffer
mitigation
required?
6f
Zone 1
impact
(square
feet )
6g
Zone 2
impact
(square
feet
B1
Yes/No
B2
Yes /No
B3
Yes /No
B4
Yes /No
B5
Yes /No
B6
Yes /No
6h Total Buffer Impacts:
61 Comments
Page 5 of 1,0

D. Impact Justification and Mitigation
1. Avoidance,and Minimization
'1a Specifically describe measures taken °to avoid or minimize,the proposed impacts in designing,prolect
An existing'road crosses the,road side ditch, which i&not being altered and will be used as thefstarting point for the access easement American
Towers, originally had „by landowner request,Jt 6 proposed.lease area entirely`in the woods After negotiating with,the landowner, American Towers
convinced him to allow them to move the tower partially'into the - agricultural'field as,to avoid disturbance of as much wooded area as possible
lb Specifically describe measures taken to avoid or minimize the proposed impacts- through construction techniques
During construction, erosion and sediment,control barner&will be estabhshed'and American Tower Corporations Best Management,Practices will be
implemented in order to eliminate impacts outside of the proposed fill area
2 Compensatory Mitigation for Impacts to Waters of'the U.S or Waters of'the State
2a Does the project require Compensatory Mitigation for
impacts to Waters of the U S or Waters of the State?
❑ Yes ❑X No'
2b If yes, mitigation is,required by (check all that apply)
❑ DWQ ❑ Corps
2c If yes, which mitigation option will be used for this
project?
� Mitigation bank
El Payment' to in -lieu fee - program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a Name of Mitigation Bank
3b Credits Purchased (attach receipt and letter)
Type Choose one
Type Choose,one
Type Choose one
Quantity
Quantity
Quantity
3c Comments,
4. Complete, if Making a Pa ment'to °In -lieu Fee Program
4a Approval letter from in -lieu fee program is' attached
❑ Yes
4b Stream mitigation requested
linear feet
4c If using stream mitigation, stream temperature
Choose,one
4d Buffer mitigation requested,(DWQ only)
square feet
4e Riparian wetland mitigation requested
acres
4f Non - riparian wetland mitigation requested
acres
4g Coastal (tidal) wetland mitigation requested
acres
4h Comments
5. Complete if Using a Permittee Responsible Mitigation Plan
5a' If using a Permittee responsible mitigation plan, provide,a description of the proposed mitigation plan
Page 6 of 10
PCN Form — Version 144 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) —required' by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
Yes XQ No
6b If yes, then identify'the square feet of impact to each zone of the riparian buffer that requires mitigation Calculate the
amount of mitigation,required-
Zone
6c
Reason °for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
15
6f Total buffer mitigation required:
6g If buffer mitigation is required, discuss,what type of mitigation is proposed,(e g , payment to pnvate,mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund)
6h Comments,
Page 7 of 40

E.
Stormwater Management +and Diffuse Flow Plan (required by DWQ)
1
Diffuse Flow Plan
1a
Does`the project include or is it adlacent•to protected riparian buffers identified
❑ Yes X❑ No
within one of the NC Riparian Buffer Protection, Rules?
1b�
If yes, then isia diffuse,fiow plan included? If no, explain why
❑ Yes ❑ No
2.
Stormwater-Management Plan
2a
What,is the overall percent imperviousness,of this project?
%
2b
Does this project re uire:a Stormwater Management Plan?
❑ Yes []No
2c
If,this protect DOES NOT require4a Stormwater Management Plan, explain why
American Tower`Corpo-ration handles-all zoning and permitting separate from wetland permitting If necessary, a State +Stormwater Management Plan
will
be obtained
2d
Ifthis project DOES require a Stormwater Management Plan,'then pro"vide,a brief; narrative, description of the plan
2e
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a
In which local government's jurisdiction is this project?'
❑ Phase II
❑ NSW
3b
Which of the following locally- implemented stormwater management programs
❑ USMP
apply (check all that�apply)
❑ Water,Supply Watershed
❑ Other
3c Has the.approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
,attached?
4. DWQ Stormwater Program Review
L]Coastal counties
❑HQW
4a
Which ofithe following state- implemented stormwater management programs apply
❑ORW
(check all that apply)
❑Session Law 2006 -246
❑ Other
4b
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
5.
DWQ 401 Unit Stormwater Review'
5a
Does the, Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No '
5b
Have all of'the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1 4 January 2009

F. Supplementary Information
1.
Environmental Documentation (DWQ)Requirement)
1a
Does the project involve an expenditure of public (federal /state /local) funds or the
El Yes
❑ No
use of public (federal /state) land?
lb
If you answered 'yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements ofthe National or State
❑Yes
❑ No
(North Carolina) Environmental' Policy Act;(NEPA/SEPA)?
1c
If'you answered "yes" to the above,'has the document review,been finalized by the
State Clearing House? '(If so, attach a copy of the NEPA or SEPA final approval
❑ Yes
❑ No
letter ) I
Comments
2.
Violations (DWQ Requirement)
2a
Is the site imviolation of DWQ Wetland Rules (15A NCAC 2H 0500), Isolated
Wetland Rules (15A NCAG 2H 1300), DWQ Surface Water•or Wetland Standards,
❑ Yes
X❑ No
or Riparian Buffer Rules (15A NCAC 2B 0200)?
2b,
Is this an after - the -fact permit application?
El Yes
❑X No
2c
If you answered "yes" to one or both of the above questions,,provide an explanation of the,violation(s)
3.
Cumulative Impacts (DWQ Requirement)
3a
Will this project (based on past and reasonably anticipated future impacts) result in
❑Yes
❑X No
additional development, which could impact nearby downstream water quality
3b
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance With,the
most recent DWQ policy If you answered "no," provide a short narrative description
4.
Sewage Disposal (DWQ Requirement)
4a Clearly detail the ultimate treatment methods and disposition (non - discharge or discharge) ofwastewater generated from
the °proposed project, or available capacity of the subject facility
,No sewage will,be generated on -site-
Page 9 of 10
PCN Form — Version 1 4 January 2009

5: Endangered Species and,Designated'Critical Habitaf(Corps Requirement)
5a. '.Wlfthis project, occur in,or,near, an areawith federally- protected species or,
� Yes ©No
hatiitat�
56. Have•you-,ctf6W d,inrithsttie USFWS:conceming Endangered,Species Act
©Yes, D,No
impacts?
5c. If yes, indicate the,USEWS Field Office you;have•contacted.
ReleigF
5d. What data sources did yod,use to determine whether your site,would 'impact Endangered- Specie`s of De'sigrWed� CnticaP
Habitat?
The,USFWS 'e 'dan64ed�and threatened. species lists'and cnticathabitat map's ,
6: Essential.Flsh Habitat (Corps Requirement)
6a. *Il this=project;occur•in ornear an area designated,as essential•fsh,habitat ?'
❑ Yes3 ❑X No
6b. AWhat data sources did:you,,useato determ4ne3 wtiether.your site would'impacf Essenbal Fish`Habiia'O'
NOAA Essential FistiHabitat Mapper
7: Historiaor P.reliistoriaCulturalResourdes '(Corps Requirement)
7a:'Will,this project occur in or near an ana,that the'state, federel'ortnbal
gavernnierits'have�designated as,having Historic,or.c �itural,preservation
;status (e gt, Nati&i I-Histonc trust designation or`properties`significant, in
Yes, Ox No
N66 Carohnafiisto y,and archaeology)?
7,b.1°What data,sources,did you,use'to determine,whether,your'site would impact historic,or, archeological resources?
The NC HPOWEB GIS database was reviewed, fliers were no National Register of Histonc Places hsted;or, ehgible sltes'in the proidd area' In- addition
the NC Historic Preservation Office responded wa,the NC Tower Form on January 28,-2014 that the project would not affect historic properties ,
8: Flood,Zone;D"esignaGon (Corps,RequRement)
8a: Wll °this "project occur-'in a FEMA=designated 100 -year floodplain?
px .Yesr ❑•No
8b , If•yes yes,*-t "s FEMA,requirerhe6t6:,
' The,BFE at;the`subjectsite has been° determined,to,bes22.5'feet`AMSL Federal standards requlre.that the finished fioorelevation ofstruciures
con`stnictetl within the 100 year flood zone be;elevated,at least one foot above_BFE' Existing,grourid,surface e16viii n within'the 'proposed, - equipment ,
compDtihd,'108 AMSL Therefore; flriistied,floor elerraGon'of all equipment within,the proposed facility will tie;at >18 7 feet AMSL orhigher or at
{feet
(east 0.7,feet above existing grade, meeting federal and local'standards for projects' located within wmapped Special Flood Haiard'Area.
8c: What sources) did.you use "to make -,the floodplairi'determinabon ?.
The,FEMA,mapping website Map;Number 3720338200J
Nicholas °Car`niean
09=25 =2014
Applicant/Agent's?Printed Name_
<< .. Ap icanUAgdnt's Signature`
Date
(A nt`s stgnature,is valid only'if an authoniatron
letter from the applicant is rovided -
,Page 10'of;10

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Map Unit Legend
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am Conservation Service National Cooperative Sod Survey Page 3 of 3

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U.S.-DEPARTMENT OF f4bMIfL4ND SECURITY ELtVATiOWICERTIFICATE 660-=8
Federal Emergency Managerniint Agency Exorei`Mirch 31', 2012
National Flood Insurance Prognmi Important' ;Read the Instructions on pages 1-9. OMBft. f
SECTION A - PROPERTY INFORMATION compgriv U":.
.Al. Building,Ownees,Narne Palli;7%"ber,
A2 Building Streel'Address (including'Apt. UfK Suite, andfor.Bldg. No.) or P.O Routaend Box No. 7
_�v
'A4. Btdkrm
9 Usd (e.q, 1160endid; Non - Residential, Addition, Accessory, etc.)
a t_3� -�, Lwg._a.Lq3- 3!�4,e_c, NAD 1983
AS. Attach at least 2 photo _mphs of Ifie'bi J�_,
'AS. Lab Vitud - Let. L- -Al I
HDrkontai battion: ❑ NAD, 1927
.g nq if th� Cbrt Ils'being used to obtain flood Insurance;
'AS. For a building with a -avMspace--or diclosij*ar IV e (0 a
A§. For abuildingykhanankhed garage
4Y Squaiefboftigb of aww1space or enclosure(s) sq 111 .6) Squam'fo6*e
- _of,Wodmd garage SO
b) No.- of permanent good - openings in the dwAspacd or 'b) No.'of pennarient flotid,'opeitings lathe aftachedtarage
enclosure - grade
-1 11
- , (s) Whn 1.0 foot above grade withimim -foot aboveikimpoent grade
C)Jotal hiii am 6f,066-d openings in A8.b sq'In -6) Tofiil net area of flood.openings1it A9.6, sq'In
d) 'Eng!neeredflood'openthga?, E] -Yes: []'No d) Engineered flood openings? [3 Yes [] No
1ECTION B - FLOOD INSURANCE RATFAIIAP 1F1RWn,1NF:n2MA'nnM
B4. MaWanel Number
135• Suffix
B6. FIRM - Index
WAN Pawl
EffectivilRevised Dite
B8. Flood
I
Zone s)
B9. Base Flood'Elevationffl,(Zone -
AO` ba6iftood!de*)'
Diu. 'Ru1cw" ule source GFule t5ase HOCK! LKWAM (13FE) data or base flood depth entered ,in-Item B9.
❑ FIS Profile 'EIFIRM donimur* , 13 Determined
, ,
B11: indicate elevation datum,used far BFE in item Em. 1:1 VD 1!329 Qj*V0,1686 ❑ Other•(Describe)
B12. lathe buildiing locafad in a Coastal Barrier Resources Syst6m-(CBRS)_6iea &Offierwise,Protected Area (OISA)? Q Yes N 0
Designation Date_— - 0 CBRS [] OPA _J�t
'SECTION C,- BUIWING ELEwnowff
ORMATION*(SURYEY REQUIRED)
2C1. Building elevailons are'based =, '
Y�V be n&
C0q"0rkDr�gS* [:]_6uJ1dIng,UnderdonsWctId6- ❑ Fmlshed Contrition
`*knew Elevation Certificate mftn cmish tton of the building is complete.,
,C2' ElevOons'—Zmms Al, -A3-0, AE, AH,A,l(iv[M BEE, VE,Vl-=,,V, (wit h BM; ARAwAAOvAF;Ai;IAl-Am,,ARtAj4,ARiAo. Compete, items C2.,a_h
belowscoordingtothe'buildin 411 "' ­ lriiteniA7. UsethesarnedatumastfidBFE.
_g, JagTin4ecilled
BenchmarkUdized C7i� Dam
ConversionlComments;
Check the measurement used.,
a) 'Top of odom,floor (including basement; ovoilspace, or enclosure Roo. x- fieet -meters (Puerto Rlco,only)
P) Top of the next highei floor 1-1-A Iiiet me!)Eiri (Puerto Rim only)
q), Bottom of the ' ImYW twdzontW structural member (V Zones only) ,;:1.q feet 0,ntetdi (Puerto Rico only)
-
d) Atla6ieii - ' 6(Iqpqf sIab) nJeet ❑ meters (Puerto Rico only)
;Lowest elevation of machinery'pr equi 'a I
q _ pment semi ding. feet Elmeten, (Puerto Rico only)
the bull
(Describe Im of equipment and 166611on in C&fiments),
ly Lowest adjacent ffin'ishedD graft next to bulld�hg (LAGY ❑ fee ❑ meters,(PuertD -Rico only)
6). Highest ad*ent (flniihed) graide next to building (HAG) !Z.-
, Q W ❑ meters (Pi►erto Fkico only),
h); Lowest adlacert grade at bwast elevation of deck orstaim,'Including 4f, Pleat meters Ouerto Rico only)
SECTION D -SURVEYOR; ENGINEER,-ORARCWMCT CERTIMATION
anon hs to tie signm and sealed by a land, surveyor, enginew, or archilect'authorized by IRW to car" elevabon
I ce*;Ihat ffib"#6wMftft on this C610cate represents aw bast efforts to *dallokt the dam .6wftbm
6M am� fatie Amnent may be,ptmis�te by rm orkmAsonment uixf& 18 U.S- -cbd&,sktbh i6i.
Check hem If coriardnts amOmfted on back of form, Wm latitude and Longitude In SectionWOMM-ided by a
licensed land surv%ror? .[].,No
L J Ryes
FEMA Fbirrh,81-31, Mat 09 See m%ibrse,sIde Ibr;oorvlinuauon. Replaces all�pnrAous editions,

IMPORTANT: In,these spaces,•copy the,corresponding Information from,Section_ A. For Insurance`Company Use:
6.
Building Street Address' d Unt ;Suite, and/or Bldg No )'or P O ,Route and Box No , Policy Number
City f Slitk I ZIP Code Company,NAIC Number
SECTION D - .SURVEYOR.-ENGINEER, OR ARCHITECT CERTIFICATION "(CONTINUED)
Copy both'sides of this Elevation
Comments `
Signature
SECTIOWE - BUILDING
(1) eommunity'official;,(2) insurance agent/company, and (3) building owner.
-Dal
INFORMATION (SURVEY NOT
i., ill A, a,
E AO
,For Zones AO and A (without BFE) „eor*ete Items E1 -E5. If the' Certificate is;jntended to support a LOMA,or LOMR- F`repuest, complete Sections A, b.
and C: For Items E7-E4, use natural grade, ii available. Check the measurement used Iii Puerto Rico oriyi, enter'meters_
El. Provide elevation Information for the following and check, the appropriate boxes to show whether the elevation, is above or below the,highest'adracent
grade (IiAG) and fhe`iowest adjacent grade (IAG): ,
a) Top of bottom Boor (indtidmg baseineM, craiMspaoe, or enclosure) is y r! ❑feet ❑meters ❑above or ❑below the tiAG
b) Top of bottom floor (including basement crawtspace, or enclosure) is'�ra 1 =❑feet ❑meters ❑above or ❑below the LAG.
3E2 For Building Diagrams 8 9.with permanent flood, openings pirovided'in Se Items'8 and/or 9;(see a es 8-9,of Instructions), the,next higher floor
(elevaUDnb In the diagrams)_Of the building is_ ❑feet_ (_J meters E] above or` �beiow ttie HAG
E3. Attadted,gaMge (top of slab) is � _ ❑ feet,0 meters ❑ attove or Q below the HAG:
E4. Top of platfgmt of,madunery and/or ettuipment servicing the building is' i ❑feet, Q' meters ❑ above or .Q below the HAG.
,E5 Zone AO ditly: If no flood depth number is available,-is the top of the bottom floor elevated in ecooManee with'the, community's floodplain management
ordinance? l❑ Yes, ❑ No',[_-] Unknown The,local,offiaal must certify,this information in Section G
'SECTION F = PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property oamer or owner's-authorized representative who'completes Sections A, B. and E for°Zone A °(without a FEMA- issued,or community4sued BFE)
or Zone AO must sign here. `The stafemerits /n,Sedrons A, B, arirl,t fifty correct to the best,of rr►y knowledge_
Property Owner's or Owner 's'Authorized'Representatrve's Name
Address` L City Ste ZIP Code
i.
Signature l Da Tel qe r- ;
❑ Check here if attachments
SECTION G,,- COMMUNITY' INFORMATION'(OPTiONAL) _
:aroffidal who is authonzed,by.lawpr ordinance to administer the community's floodpiam management`ordinance can comptete,z:�
of fins Elevation Certificate. Comptete the,appbcabie item(s) and sign below Check the measurement used in items G8 and G9:
G1 Q The information in Seetion.C'was taken from other documentation that has been signed and sealed by_a licensed surveyor, engineer; or architect who
,ls,authorized'by law,to certify elevation inforrnatiori (Indicate the`s6iirc6i6nd date of the elevatidn dataitn the Comments area below.)
G2- ❑ A community official completed Section E for a building located in Zone A (without a FEMX�med or cormmur0y,4ssued BFE)`or Zone AO
G3: The „following information (llama G4-69 is provided for oommunilyfloodpiain management purposes
G4 Permit Number ,,G5 Date Permit Issued Ge. Date Certiflcate'Of ComphancelOccupancy Issued
,G7` This permit has been'issued for ❑ New Construction {] Substantial Improvement,
G8 Elevation'& as -built lowest floor (including basement) of the,burlding ❑ feet ❑ meters (PR) Datum
G9. BFE or (m Zone AO) depth of flooding at the byildirig site ❑ feet ❑� meters +(PR) Datum
GI Community's design flood elevation ❑ feet ❑ meters (PR) Datum
Local Official's Name Titie
Community Name Telephone - t
Signature' l V Date
Comments
❑'ChecWhere dattadiments
FEMA Form 81 -31, Mar 09 Replaces all,'pt>?vious editions