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25C-255 (10) BP-2024-0976 23 FAIR ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25C-255-001 CITY OF NORTHAMPTON Permit: Addition PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-0976 PERMISSION IS HEREBY GRANTED TO: Project# ADDITION 2024 Contractor: License: OXBOW DESIGN BUILD Est. Cost: 203138 COOPERATIVE INC 119303 Const.Class: Exp.Date:01/12/2028 Use Group: Owner: YANIS, LIA&CHRISTOPHER E.TOURLOUKIS Lot Size(sq.ft.) Zoning: SC Applicant: OXBOW DESIGN BUILD COOPERATIVE INC Applicant Address Phone: Insurance: 122 PLEASANT ST DUITE 109 (413)527-9000 WCC5005031952 EASTHAMPTON, MA 01027 ISSUED ON: 09/03/2024 TO PERFORM THE FOLLOWING WORK: REAR 2 STORY ADDITION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: (i� Fees Paid: $1,523.53 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 444 The Commonwealth of Massachu ettsn / (904)4 FO ':.& Board of Building Regulations and S ar -0, Massachusetts State Building Code, 780 C Rryy4//nDino� M NIC E LITY Building Permit Application To Construct,Repair, Renovate Or DemN'Ns so�0 vise Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: /5/9-2--5V —' 76' Date Applied: KI),) ( , i( 9.. -zor Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: _23 Fair Street, 1.2 Assessors Map& Parcel Numbers 25C 25C-255 1.1 a Is this an accepted street?yes_X_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: SC residential 10,800 60 Zoning District Proposed Use Lot Area(sq II) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided N/A N/A 98 ft(inc. addition) 1.6 Water Supply: (M.G.Lc.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: B Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes12 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Lia Yanis&Chris Tourloukis Northampton,MA 01027 Name(Print) City,State,ZIP 23 Fair Street 413-262-1549 lia.r.yanis@gmail.com,ctourlouki@gmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied a Repairs(s) 0 Alteration(s) 0 Addition 12 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work':Rear 2-story addition SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building S 173,690 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $7,728 ❑ Standard City/Town Application Fee ❑Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $1,452 2. Other Fees: $ 4. Mechanical (HVAC) $20 268 List: 5. Mechanical Fire Suppression) ( $0 Total All Fees: '3•c Check No. 115 Check Amot1 :• 1)6 Cash Amount: 6. Total Project Cost: S 203,138 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-119303 01/12/2028 Emily Berge License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 122 Pleasant St No.and Street Type Description Easthampton,MA 01073 U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-667-7257 emily@oxbowdesignbuild.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 197929 02/06/2026 Oxbow Design Build Cooperative,Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 122 Pleasant Street.suite 109 admin@oxbowdesignbuild.com No.and Street Email address Easthampton,MA 01027 413-527-9000 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes No O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Oxbow Design Build Cooperative,Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. Lia Yanis 1la. 9-WS Jul 30 2024 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. � • L3 Emily Berge Jul 30 2024 Print Owner's or Authorized Agent's Name(Electronic Signature Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) 2072 (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) 2072 Habitable room count 11(including proposed addition) Number of fireplaces 0 Number of bedrooms 3 Number of bathrooms 2 Number of half/baths 1 Type of heating system heat pump/minisplits Number of decks/porches 1 Type of cooling system central air Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD Please see the accompanying file: 23-Fair-Street-PermitSet-7-18-24 Black and White.pdf page 1 (G0.01) SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton - . ri s s Massachusetts w'�s•` Sh �ci.11 DEPARTMENT OF BUILDING INSPECTIONS Sn ," ¢ t 212 Main Street • Municipal Building 9 OCa` Northampton, MA 01060 j. 3. CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 4 Summit Lock Road,Westfield MA 01085 The debris will be transported by: Western Massachusetts Demolition Corporation Name of Hauler: Signature of Applicant: Be le Date: Jul 302o2a The Commonwealth o j MassachusettsDepartment of lnrlustrial.aeridents 1 Congress Strut,Suite 100 ritiOlim trr t ..... .OW Boston,MA 02114-2017 www.mass.gov/dirt Workers'Compensation Insurance Affidavit:BuiIdersiContrsctorsfElectriciansJPlumbers. IYI HE FILED W1111 I IIE PERM,t"n c At ttIORITY. _\in iicant Information Pleas(: Print t.eetibls Name 113ua mess:Orrantzsti:.t: kiddy'ulna!it Oxbow Design Build Cooperative, Inc. Address: 122 Pleasant Street, Suite 109 CitviStateiZip: Easthampton, MA 01027 phone _-_-_: 413-527-9000 Are you iin employer?Check the appropriate tot: Type of project(required): 112 tam a employe:with 30 _cntq►loyrces ifull and An part-time)_' 7. 0 New construction ICJ t am a role proprietor or partnership wad have no einployees working for MC in $. 0 Remodeling any capacity.[No workers comp.t 5tnSnet n`yuirrrl.l 9_ 0 Demolition 301 am a hontc'owner dung all ii4oxatik myself. No worlrxs'comb.insoraii a required.]4 10 0 Building addition 3.0 I ant a homeowner and will he hiring cntitraritors to conduct all work on Illy property_ 1 ensure that all contractors either haveV4,Orkerle compensation tion insurance or are sole .I I,0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions SOI am a gertexal contractor and I have hired the sub-contractors kited on the attached sheet. These rob-contractors hare employees and have workers'comp,insulanee„ 13 Root repairs 6.0 W'c are a corporation and its officers have exercised then right ofeveinMO.piton per M .c. t4. OC11ea' 152.¢1t4),and we have no employees.[No workers'comp.insurance reynined.l 'Ally applicant that checks box tot must also till out the section below showing their wrrrk 'Wmpetwation policy utl'cxrnatierct +Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such. teontractUrs that check this box musi attached an additional shell showing the nacre(tithe s)thrcontrecturs and state whether or trot(.hose entities haw employees If the stab-contractors have employees,they must provide their workers`comp.policy number. I am an employer layer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. insurance Company Name: Associated Employers Insurance Co. ________ WCC50050319522024A 07/27/2025 Policy#ter Self-ins.Lie.#: Expiration Date: Job Site Address: 23 Fair Street caysiateizip: Northampton MA 01060 Attach a copy of the workers'compensation polio declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a tine up to S1,500.00 and/or ono-year imprisonment,as well as civil penalties in the foam of a STOP WORK ORDER and a tine of up to S250.(K)a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage yeti tication. f da herein-certify loather the pains and ll tf%�.4,r.t,r per/un that the information pro►•ided above istrue and correct. Sienature: CaJe� Date: Jul 30 2024 Phone 413.667 7257 433-6G7 7257 Of cial4 61i11'•71157rot write in this area,to be completed b>"city or town official Cits or Town: Permit/License# Issuing Authority (circle one): I.Board of Health 2. Building Department 3.CityiTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone*: xodo sign Audit Trail by apryse Document Details Title 23 Fair-Building Permit Application File Name 23 Fair- building permit application7.22.pdf Document ID 47ea040664e24a7c8d8b149263ab94f8 Fingerprint 8f2497314753cae3cc6d51 cf27388596 Status Completed Document History Document Created Document Created by Tiffany Kozash(admin@oxbowdesignbuild.com) Jul 29 2024 Fingerprint:82a03efc655da7c883ec1428cfddbc31 09:37PM UTC Document Sent Document Sent to Lia Yanis (lia.r.yanis@gmail.com) Jul 29 2024 09:37PM UTC Document Sent Document Sent to Emily Berge(emily@oxbowdesignbuild.com) Jul 29 2024 09:37PM UTC Document Viewed Document Viewed by Emily Berge (emily@oxbowdesignbuild.com) Jul 29 2024 IP: 174.242.132.92 11:26PM UTC Document Signed by Emily Berge(emily@oxbowdesignbuild.com) IP: 174.242.132.92 Document Signed Jul 30 2024 Etui Beetle Document Viewed Document Viewed by Lia Yanis(lia.r.yanis@gmail.com) Jul 30 2024 Document Signed by Lia Yanis (lia.r.yanis@gmail.com) Document Signed Jul 30 2024 02:47PM UTC Document This document has been completed. Jul 30 2024 Completed Fingerprint:812497314753cae3cc6d51cf27388596 02:47PM UTC Processed by xodo sign A�O® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/29/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Adina Edgett NAME: Alera Group,Inc. PHONE (413)586-0111 FAX (413)586-6481 Mt:,Ext): (A/C.No): 8 North King Street ADDRESS: adina.edgett@aleragroup.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Ohio Casualty Insurance Company 24074 Oxbow Design Build Cooperative,Inc. INSURER C: Associated Employers Insurance Co 11104 Attn:Carl Woodruff&Christopher Millette INSURER D: Lloyds/BRECK 122 Pleasant Street,Suite 109(upper&lower space) INSURER E: Easthampton MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 07/25 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRTR INSD TYPE OF INSURANCE A �WVD POLICY NUMBER M/UBR POLICY EFF POLICY EXP LIMITS (MDDlYYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1-1OCCUR PREMISESO(Ea occurrence) $ 500'000 MED EXP(Any one person) $ 15,000 A BKS57412882 07/01/2024 07/01/2025 PERSONAL&ADV INJURY $ 1.000,000 GEN'L AGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC 2,000,000 JECT PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO v BODILY INJURY(Per person) $ A OWNED u SCHEDULED BAS57412882 07/01/2024 07/01/2025 BODILY INJURY(Per accident) $ AUTOS ONLY HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE US057412882 07/01/2024 07/01/2025 AGGREGATE $ 1'000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EACH ACCIDENT $ 500000 C OFFICER/MEMBER EXCLUDED? n E.L. , N/A WCC50050319522024A 07/27/2024 07/27/2025 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ General Aggregate $1,000,000 Professional Liability D ANE5057894 01/25/2024 01/25/2025 Each Occurrence $1,000,000 FHA/OSHA/ADA $25,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ''"V'`'V''' ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD tj City of Northampton Kevin Ross<kross@northamptonma.gov> Building Permit Application: 23 Fair St Emily Berge <emily@oxbowdesignbuild.com> Thu,Aug 29, 2024 at 5:14 PM To: Kevin Ross <kross@northamptonma.gov> Cc:Tiffany Kozash <tiffany@oxbowdesignbuild.com> Hey Kevin, Yes our electrical and insulation plans for the addition will be up to code. I have copied from the electric and the insulation company's quotes so you can see their scope of work. Smokes will be added in the offices as well as outside/top and bottom of stairs once it is determined if there currently are any in range, and if not they will be added. I apologize the plans didn't specify that information. Please let me know if there is anything else. Emily . Living Room 1 St floor Wire for receptacles as per code Wire for central light with box capable of supporting a fan and 3 way switch Office 1 New addition Wire for receptacles as per code. Wire for central light with box capable of supporting a fan with switch by door Wire for and supply photo smoke d?JectQJ. Wire for closet light on switch. Office 2 New addition Wire for receptacles as per code. Wire for central light with box capable of supporting a fan with switch by door Wire for and supply photo smoke detgctar. Wire for closet light on switch. Stairs and Hallway Smokes TBD UNation Measure Depth r:•R-Value a1Sf_c Addition Attic Flat Cellulose Open Blow 16" 60 300 Addition Attic Flat Air Sealing N/A N/A _ 2 Addition Exterior Walls Cellulose Densepack 8" 42 688 Addition Crawlspace Ceiling Rockwool 12" 42 300 Rim Band between 1st&2nd Floor Thermax 6" 42 49 (Quoted text hidden] U.S. DEPARTMENT OF HOMELAND SECURITY OMB Control No.1660-0008 Federal Emergency Management Agency Expiration Date:06/30/2026 National Flood Insurance Program ELEVATION CERTIFICATE IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON PAGES 9-19 Copy all pages of this Elevation Certificate and all attachments for(1)community official,(2)insurance agent/company,and (3)building owner. SECTION A-PROPERTY INFORMATION 1 FOR INSURANCE COMPANY USE Al. Building Owner's Name: L i a Yon'S o'C'4 r'S c>/4 e,- 1(r/oQk#S Policy Number rcZ. nuuumg nutlet rluuress tuuauarng Hpr.,menu.none,ancror mug.No.;or r.v. rcoure arm Dux Company NAIL Number: City: A/v r '"'"o''7 State: /7/47 ZIP Code: O/' ' A3. Property Description(e.g.,Lot and Block Numbers or Legal Description)and/or Tax Parcel Number: /42:7,1 2S- 4/ 2,5-G o o /°f 2 2/ A4. Building Use (e.g., Residential, Non-Residential,Addition,Accessory,etc.): o5idee7 1•1 al A5. Latitude/Longitude: Lat.N 92-/y 3D./9 Long.6J 7Z-31-Z 1.J7Horizontal Datum: ONAD 1927 ONAD 1983 `,WGS 84 A6. Attach at least two and when possible four clear photographs(one for each side)of the building(see Form pages 7 and 8). A7. Building Diagram Number: S A8. For a building with a crawlspace or enclosure(s): a) Square footage of crawlspace or enclosure(s): 704) sq.ft. b) Is there at least one permanent flood opening on two different sides of each enclosed area? *Yes iNo '_§NIA c) Enter number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade: Non-engineered flood openings: G Engineered flood openings: d) Total net open area of non-engineered flood openings in A8.c: S-90 sq. in. e) Total rated area of engineered flood openings in A8.c(attach documentation-see Instructions): sq.ft. f) Sum of A8.d and A8.e rated area(if applicable-see Instructions): 3, 7,5- sq.ft. A9. For a building with an attached garage: a) Square footage of attached garage: N/A sq.ft. b) Is there at least one permanent flood opening on two different sides of the attached garage? JYes No N/A c) Enter number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade: Non-engineered flood openings: Engineered flood openings: d) Total net open area of non-engineered flood openings in A9.c: sq.in. e) Total rated area of engineered flood openings in A9.c(attach documentation--see Instructions): sq.ft. f) Sum of A9.d and A9.e rated area(if applicable-see Instructions): sq.ft. SECTION B-FLOOD INSURANCE RATE MAP(FIRM) INFORMATION 81.a. NFIP Community Name: Al o r 1-L!aMP/vn B1.b.NFIP Community Identification Number. LSD /6'7 B2.County Name: AZ��nPS`i i.- C B3.State: "1 f4 B4. Map/Panel No.: po L Z B5.Suffix: /q B6.FIRM Index Date: /f 7B B7. PIRM Panel Effective/Revised Date: Ipi-- ? /9J8 B8.Flood Zone(s): - B9. Base Flood Elevation(s)(BFE)(Zone AO,use Base Flood Depth): B10. Indicate the source of the BFE data or Base Flood Depth entered in Item B9: +'FIR FIRM ®rnmmunity rlatarminari °Other: 611. Indicate elevation datum used for BFE in Item B9: tillNGVD 1929 Or.rnvn.oua DOther/Source: B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ^Yes IIIENo Designation OCBRS s";OPA B13. Is the building located seaward of the Limit of Moderate Wave Action(LiMWA)? ;Yes etNo ELEVATION CERTIFICATE IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON PAGES 9-19 Building Street Address(including Apt., Unit,Suite,and/or Bldg. No.)or P.O. Route and Box No.: FOR INSURANCE COMPANY USE s Policy Number: City: Dior 1-A z/,-i f /V'1 State: ii411 ZIP Code: C/P 6 Company NAIC Number: SECTION C-BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: .Construction Drawings' Building Under Construction' ;'Finished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations-Zones Al-A30,AE,AH,AO,A(with BFE),VE,V1-V30,V(with BFE),AR,ARIA,AR/AE,AR/A1-A30,AR/AH,ARJAO, A99. Complete Items C2.a-h below according to the Building Diagram specified in Item A7.In Puerto Rico only,enter meters. Benchmark Utilized: SG r IJ e y G r��r G f S Vertical Datum: 1Y t`W e8 Indicate elevation datum used for the elevations in items a)through h)below. _ NGVD 1929 *NAVD 19RR :'Other: Datum used for building elevations must be the same as that used for the BFE. Conversion factor used? Yes :No If Yes,describe the source of the conversion factor in the Section D Comments area. Check the measurement used: a) Top of bottom floor(including basement,crawlspace,or enclosure floor): J Za 4 14 feet -: meters b) Top of the next higher floor(see Instructions): /2C- CI ' '1 feet f t meters c) Bottom of the lowest horizontal structural member(see Instructions): /2 ' r f? feet meters d) Attached garage(top of slab): feetc= meters e) Lowest elevation of Machinery and Equipment(M&E)servicing the building (describe type of M&E and location in Section D Comments area): / 2 6. e' R? feet meters f) Lowest Adjacent Grade(LAG)next to building: LNatural ',.°Finished %Ze. feet " meters g) Highest Adjacent Grade(HAG)next to building: 1::Natural ' Finished /2/- / feet _ meters h) Finished LAG at lowest elevation of attached deck or stairs,including structural support: i 04->: 7 lr3 feet meters SECTION D-SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by state law to certify elevation information. I certify that the information on this Certificate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code,Section 1001. Were latitude and longitude in Section A provided by a licensed land surveyor? t Yes No L. Check here if attachments and describe in the Comments area. Certifier's Name: G`/w�rq' ( /'iiJ. zy,✓sk, License Number:/0 l3 32''cfq Place Seal Here Title: / )a f• 2. ?r /7 S tc ry y �` j" Company Name: 6 c>cv l: in 1._,.szy n 51J, J I-.. f ;ARD Y Address: / `6' old )2Ji n J2ir-1 rr G- �_ ��,/ 14USZ1'! t(i City: /"�P.7 �i Q /s'/ State: !YJ g ZIP Code: CJ/ 3C�J ' yi�nin 32 44 t • d. 4f% Date: g/e3. 2 4/ aLfs``t- Telephone: 4/3 '7 241 '9 � /-tm.,//S 6 ?:/. Ext.: Email: t�d�-� i 6a»9 Copy ell pages of this Elevation Cortificnto and all ott achmonts for(1)community official. (2)incuronce agent/company.and(3)building owner. Comments(including source of conversion factor in C2;type of equipment and location per C2.e;and description of any attachments): , S eid • �,.� .=/ j-is; �_ r!. r�,�5 "0ar(' Wive',- — )O 3 9 ELEVATION CERTIFICATE IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON PAGES 9-19 Building Street Address(including Apt., Unit,Suite,and/or Bldg.No.)or P.O. Route and Box No.: FOR INSURANCE COMPANY USE S7-• kr Policy Number: City: /V .4.7 State: /YJ, ZIP Code: cam/O Gc> Company NAIL Number: SECTION H—BUILDING'S FIRST FLOOR HEIGHT INFORMATION FOR ALL ZONES (SURVEY NOT REQUIRED) (FOR INSURANCE PURPOSES ONLY) The property owner,owner's authorized representative,or local floodplain management official may complete Section H for all flood zones to determine the building's first floor height for insurance purposes.Sections A,B,and I must also be completed. Enter heights to the nearest tenth of a foot(nearest tenth of a meter in Puerto Rico).Reference the Foundation Type Diagrams(at the end of Section H Instructions)and the appropriate Building Diagrams(at the end of Section I Instructions) to complete this section. H1. Provide the height of the top of the floor(as indicated in Foundation Type Diagrams)above the Lowest Adjacent Grade(LAG): a) For Building Diagrams 1A,1B,3,and 5-9.Top of bottom 5,, 3 efeet metora ahrrve the I Ar, floor(include above-grade floors only for buildings with subgrade crawlspaces or enclosure floors)is: b) For Building Diagrams 2A,2B,4,and 6-9.Top of next feet __:mPtorc ahnve the I AP. higher floor(i.e.,the floor above basement,crawlspace,or enclosure floor)is: H2. Is all Machinery and Equipment servicing the building (as listed in Item H2 instructions)elevated to or above the floor indicated by the H2 arrow(shown in the Foundation Type Diagrams at end of Section H instructions)for the appropriate Building Diagram? bYes •'WI SECTION I-PROPERTY OWNER (OR OWNER'S AUTHORIZED REPRESENTATIVE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A, B,and H must sign here. The statements in Sections A, B, and H are correct to the best of my knowledge. Note: If the local floodplain management official completed Section H,they should indicate in item G2.b and sign Section G. CiCheck here if attachments are provided(including required photos)and describe each attachment in the Comments area. Property Owner or Owner's Authorized Representative Name: Address: City: State: ZIP Code: Date: Telephone: Ext.: Email: Comments: ELEVATION CERTIFICATE IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON PAGES 9-19 BUILDING PHOTOGRAPHS See Instructions for Item A6. Building Street Address(including Apt.,Unit,Suite,and/or Bldg. No.)or P.O.Route and Box No.: FOR INSURANCE COMPANY USE 03 A"-�I" SA• Policy Number: City: /\-l't'/" P'WIAJD" State: 444 ZIP Code: 0/4'4 O Company NAIL Number: Instructions:Insert below at least two and when possible four photographs showing each side of the building(for example,may only be able to take front and back pictures of townhouses/rowhouses). Identify all photographs with the date taken and"Front View,""Rear View," "Right Side View,"or"Left Side View."Photographs must show the foundation.When flood openings are present, include at least one close- up photograph of representative flood openings or vents,as indicated in Sections A8 and A9. Photo One Y• v -, :}�A L `,.ii1 I �r t `.. II i1111 lit t Atli ', -�, t" —" • h y I lit, r ." y • .. ter_ t J • 1810 - d.Y . y S p o 4 /� ors GII v3 Clear Photo One I Photo One Caption: �-�� Photo Two - \i, _ >. 4 sue__,__' . __ ; mc-�x� -' Wit' L. Photo Two Captio 2-e 7 y" d r /�va*S near Photo Two ELEVATION CERTIFICATE IMPORTANT:MUST FOLLOW THE INSTRUCTIONS ON PAGES 9-19 BUILDING PHOTOGRAPHS Continuation Page Building Street Address(including Apt., Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No.: FOR INSURANCE COMPANY USE Policy Number: City: State: ZIP Code: - Company NAIC Number: Insert the third and fourth photographs below. Identify all photographs with the date taken and"Front View,""Rear View," "Right Side View," or"Left Side View."When flood openings are present, include at least one close-up photograph of representative flood openings or vents, as indicated in Sections A8 and A9. Photo Three Photo Three Caption: c"..r71. S/d e c•-' -f 4/474,S e_. 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