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O.M.B. NO. 3067-0077

Expires July 31, 2002

FEDERAL EMERGENCY MANAGEMENT AGENCY

NATIONAL FLOOD INSURANCE PROGRAM

FLOODPROOFING CERTIFICATE

FOR NON-RESIDENTIAL STRUCTURES

The floodproofing of non-residential buildings may be permitted as an alternative to elevating to or above the Base Flood Elevation; however, a

floodproofing design certification is required. This form is to be used for that certification. Floodproofing of a residential building does not alter a

community’s floodplain management elevation requirements or affect the insurance rating unless the community has been issued an exception by

FEMA to allow floodproofed residential basements. The permitting of a floodproofed residential basement requires a separate certification specifying

that the design complies with the local floodplain management ordinance.

FOR INSURANCE COMPANY USE

POLICY NUMBER

BUILDING OWNER’S NAME

STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. Number) OR P.O. ROUTE AND BOX NUMBER

COMPANY NAIC NUMBER

OTHER DESCRIPTION (Lot and Block Numbers, etc.)

CITY

STATE

ZIP CODE

SECTION I FLOOD INSURANCE RATE MAP (FIRM) INFORMATION

Provide the following from the proper FIRM:

COMMUNITY NUMBER

PANEL NUMBER

SUFFIX

DATE OF FIRM INDEX

FIRM ZONE

BASE FLOOD ELEVATION

(In AO Zones, Use Depth)

SECTION II FLOODPROOFING INFORMATION (By a Registered Professional Engineer or Architect)

Floodproofing Design Elevation Information:

Building is floodproofed to an elevation of ................................... feet NGVD. (Elevation datum used must be the same as that on the FIRM.)

Height of floodproofing on the building above the lowest adjacent grade is ........................................ feet.

(NOTE: for insurance rating purposes, the building’s floodproofed design elevation must be at least one foot above the Base Flood Elevation to

receive rating credit. If the building is floodproofed only to the Base Flood Elevation, then the building’s insurance rating will result in a higher

premium.)

SECTION III CERTIFICATION (By Registered Professional Engineer or Architect)

Non-Residential Floodproofed Construction Certification:

I certify that, based upon development and/or review of structural design, specifications, and plans for construction, the design and methods of

construction are in accordance with accepted standards of practice for meeting the following provisions:

The structure, together with attendant utilities and sanitary facilities, is watertight to the floodproofed design elevation indicated above, with

walls that are substantially impermeable to the passage of water.

All structural components are capable of resisting hydrostatic and hydrodynamic flood forces, including the effects of buoyancy, and

anticipated debris impact forces.

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.

CERTIFIER’S NAME

LICENSE NUMBER (or Affix Seal)

TITLE

COMPANY NAME

ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE

DATE

PHONE

Copies should be made of this Certificate for: 1) community official, 2) Insurance agent/company, and 3) building owner.

FEMA Form 81-65, AUG 99

Replaces all previous editions

F-056 (8/99)

Fema Form 81-65 - Floodproofing Certificate For Non-Residential Structures - 1999-2002

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