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HomeMy WebLinkAboutElevation Certificate 6/5/25 National Flood Insurance Program Elevation Certificate and Instructions 2022 EDITION /1/,t4t Afir9,t O '•‘0, \r Ir.‹sl4 N D SEGO U.S. DEPARTMENT OF HOMELAND SECURITY OMB Control No.1660-0008 Expiration Date:06/30/2026 Federal Emergency Management Agency National Flood Insurance Program ELEVATION CERTIFICATE AND INSTRUCTIONS iS'r,.' Public reporting burden for this data collection is estimated to average 3.75 hours per response.The burden estimate includes the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street SW,Washington, DC 20742, Paperwork Reduction Project(1660-0008). NOTE: Do not send your completed form to this address. a x: � Authority:Title 44 CFR§61.7 and 61.8. Principal Purpose(s):This information is being collected for the primary purpose of documenting compliance with National Flood Insurance Program (NFIP)floodplain management ordinances for new or substantially improved structures in designated Special Flood Hazard Areas.This form may also be used as an optional tool for a Letter of Map Amendment(LOMA), Conditional LOMA(CLOMA), Letter of Map Revision Based on Fill (LOMR-F), or Conditional LOMR-F(CLOMR-F), or for flood insurance rating purposes in any flood zone. Routine Use(s):The information on this form may be disclosed as generally permitted under 5 U.S.C. §552a(b)of the Privacy Act of 1974, as amended.This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA-003—National Flood Insurance Program Files System of Records Notice 79 Fed. Reg. 28747(May 19,2014)and upon written request,written consent, by agreement, or as required by law. Disclosure:The disclosure of information on this form is voluntary; however, failure to provide the information requested may impact the flood insurance premium through the NFIP. Information will only be released as permitted by law. ,P SE OF THE ELEVATION CERTIFICATE The Elevation Certificate is an important administrative tool of the NFIP. It can be used to provide elevation information necessary to ensure compliance with community floodplain management ordinances,to inform the proper insurance premium, and to support a request for a LOMA, CLOMA, LOMR-F, or CLOMR-F. The Elevation Certificate is used to document floodplain management compliance for Post-Flood Insurance Rate Map(FIRM)buildings, which are buildings constructed after publication of the FIRM, located in flood Zones A1—A30,AE,AH,AO,A(with Base Flood Elevation (BFE)),VE,V1—V30,V(with BFE),AR,AR/A,AR/AE,AR/A1—A30,AR/AH,AR/AO, and A99. It may also be used to provide elevation information for Pre-FIRM buildings or buildings in any flood zone. As part of the agreement for making flood insurance available in a community, the NFIP requires the community to adopt floodplain management regulations that specify minimum requirements for reducing flood losses. One such requirement is for the community to obtain the elevation of the lowest floor(including basement)of all new and substantially improved buildings, and maintain a record of such information.The Elevation Certificate provides a way for a community to document compliance with the community's floodplain management ordinance. Use of this certificate does not provide a waiver of the flood insurance purchase requirement. Only a LOMA or LOMR-F from the Federal Emergency Management Agency(FEMA)can amend the FIRM and remove the federal mandate fora lending institution to require the purchase of flood insurance. However,the lending institution has the option of requiring flood insurance even if a LOMA/LOMR-F has been issued by FEMA.The Elevation Certificate may be used to support a LOMA, CLOMA, LOMR-F, or CLOMR-F request. Lowest Adjacent Grade(LAG)elevations certified by a land surveyor, engineer, or architect, as authorized by state law,will be required if the certificate is used to support a LOMA, CLOMA, LOMR-F, or CLOMR-F request.A LOMA, CLOMA, LOMR-F, or CLOMR-F request must be submitted with either a completed FEMA MT-EZ or MT-1 application package,whichever is appropriate. If the certificate will only be completed to support a LOMA, CLOMA, LOMR-F, or CLOMR-F request,there is an option to document the certified LAG elevation on the Elevation Form included in the MT-EZ and MT-1 application. This certificate is used only to certify building elevations.A separate certificate is required for floodproofing. Under the NFIP, non-residential buildings can be floodproofed up to or above the BFE.A floodproofed building is a building that has been designed and constructed to be watertight(substantially impermeable to floodwaters)below the BFE. Floodproofing of residential buildings is not permitted under the NFIP unless FEMA has granted the community an exception for residential floodproofed basements.The community must adopt standards for design and construction of floodproofed basements before FEMA will grant a basement exception. For both floodproofed non-residential buildings and residential floodproofed basements in communities that have been granted an exception by FEMA, a floodproofing certificate is required. The expiration date on the form herein does not apply to certified and completed Elevation Certificates, as a completed Elevation Certificate does not expire, unless there is a physical change to the building that invalidates information in Section A Items A8 or A9, Section C, Section E, or Section H. In addition,this form is intended for the specific building referenced in Section A and is not invalidated by the transfer of building ownership. Additional guidance can be found in FEMA Publication 467-1, Floodplain Management Bulletin:Elevation Certificate. FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 1 of 19 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 FOR INSURANCE COMPANY USE Al. Building Owner's Name: LEONARD &TERRI DiCARLO Policy Number: A2. Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No.: Company NAIC Number: 111 CROWELL ROAD City: WEST YARMOUTH State: MA ZIP Code: 02673 A3. Property Description(e.g., Lot and Block Numbers or Legal Description)and/or Tax Parcel Number: ASSESSORS MAP 17 , PARCEL 77 TITLE IN DEED BOOK 31370, PAGE 314 A4. Building Use(e.g., Residential, Non-Residential,Addition,Accessory,etc.): RESIDENTIAL A5. Latitude/Longitude: Lat.41.64087 Long.-70.24081 Horizontal Datum: ❑NAD 1927 ®NAD 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: 2B A8. For a building with a crawlspace or enclosure(s): a) Square footage of crawlspace or enclosure(s): 1,673.00 sq. ft. b) Is there at least one permanent flood opening on two different sides of each enclosed area? ❑ Yes ® No ❑ N/A c) Enter number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade: Non-engineered flood openings: 0 Engineered flood openings: 0 d) Total net open area of non-engineered flood openings in A8.c: 0.00 sq. in. e) Total rated area of engineered flood openings in A8.c(attach documentation-see Instructions): 0.00 sq. ft. f) Sum of A8.d and A8.e rated area(if applicable-see Instructions): 0.00 sq. ft. A9. For a building with an attached garage: a) Square footage of attached garage: sq. ft. b) Is there at least one permanent flood opening on two different sides of the attached garage? ❑Yes ® 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: 0 Engineered flood openings: 0 d) Total net open area of non-engineered flood openings in A9.c: 0.00 sq. in. e) Total rated area of engineered flood openings in A9.c(attach documentation-see Instructions): 0.00 sq. ft. f) Sum of A9.d and A9.e rated area (if applicable-see Instructions): 0.00 sq. ft. SECTION B-FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1.a. NFIP Community Name:YARMOUTH B1.b. NFIP Community Identification Number: 250015 B2. County Name:BARNSTABLE B3. State: MA B4. Map/Panel No.: 25001C0588 B5. Suffix:J B6. FIRM Index Date: 05/02/1977 B7. FIRM Panel Effective/Revised Date: 07/16/2014 B8. Flood Zone(s): AE B9. Base Flood Elevation(s)(BFE)(Zone AO, use Base Flood Depth): 10.8 B10. Indicate the source of the BFE data or Base Flood Depth entered in Item 69: ❑ FIS ® FIRM ❑Community Determined ❑Other: B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ®NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System (CBRS)area or Otherwise Protected Area(OPA)? ❑Yes ® No Designation Date: ❑CBRS ❑OPA B13. Is the building located seaward of the Limit of Moderate Wave Action (LiMWA)? ❑Yes ® No FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 2 of 19 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 111 CROWELL ROAD Policy Number: City: WEST YARMOUTH State: MA ZIP Code: 02673 Company NAIC Number: SECTION C—BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. 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 A1—A30,AE, AH,AO,A(with BFE),VE,V1—V30, V(with BFE),AR,AR/A,AR/AE,AR/A1—A30,AR/AH,AR/AO, A99. Complete Items C2.a—h below according to the Building Diagram specified in Item A7. In Puerto Rico only, enter meters. Benchmark Utilized: GPS RECEIVER Vertical Datum: NAVD-1988 Indicate elevation datum used for the elevations in items a)through h)below. ❑ NGVD 1929 ® NAVD 1988 ❑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): 7.06 ® feet ❑ meters b) Top of the next higher floor(see Instructions): 15.20 ® feet ❑ meters c) Bottom of the lowest horizontal structural member(see Instructions): ❑ feet ❑ meters d) Attached garage(top of slab): ❑ feet ❑ 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): 8.50 ® feet ❑ meters f) Lowest Adjacent Grade(LAG) next to building: n Natural ❑ Finished 12.10 ® feet ❑ meters g) Highest Adjacent Grade(HAG)next to building: ] Natural Finished 13.10 ® feet ❑ meters h) Finished LAG at lowest elevation of attached deck or stairs, including structural support: 12.10 ® 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. /certify that the information on this Certificate represents my best efforts to interpret the data available. 1 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? ® Yes ❑ No ❑Check here if attachments and describe in the Comments area. Certifier's Name: KIERAN J. HEALY, PLS, CFM License Number:48135 Title: SURVEY MANAGER Company Name: BSC GROUP INC Address: 349 ROUTE 28, UNIT D City: WEST YARMOUTH State: MA ZIP Code: 02673 Signature: Date: 06/04/2025 Telephone: (508) 778-8919 Ext.: 4586 Email:KHEALY@BSCGROUP.COM Place Seal Here Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insurance 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): THIS EC IS BASED ON FILL BEING BROUGHT ON SITE TO RAISE THE GRADE AROUND THE HOUSE TO BE ABOVE ELEVATION 12.1. THE WALLS AROUND THE WALKOUT STAIRS WILL ALSO BE RAISED TO ELEVATION 12.1. THE GARAGE IS NOT CONSIDERED AN ATTACHED GARAGE AS THERE IS LIVING SPACE OVERHEAD. THE INTERIOR OF THE GARAGE IS 293 S.F.AND THE GARAGE SLAB GRADE IS ELEVATION 13.1. THE BUILDING IS A SPLIT LEVEL BUT DIAGRAM 2B WAS USED AS THIS HAS A LOWER LEVEL WALKOUT. SEE PLAN FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 3 of 19 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 111 CROWELL ROAD Policy Number: City: WEST YARMOUTH State: MA ZIP Code: 02673 Company NAIC Number: SECTION E—BUILDING MEASUREMENT INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO,ZONE AR/AO,AND ZONE A (WITHOUT BFE) For Zones AO,AR/AO, and A(without BFE), complete Items El—E5. For Items El—E4, use natural grade, if available. If the Certificate is intended to support a Letter of Map Change request, complete Sections A, B, and C. Check the measurement used. In Puerto Rico only, enter meters. Building measurements are based on: ❑ Construction Drawings* ❑ Building Under Construction* ❑ Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. El. Provide measurements(C.2.a in applicable Building Diagram)for the following and check the appropriate boxes to show whether the measurement is above or below the natural HAG and the LAG. a) Top of bottom floor(including basement, crawlspace, or enclosure)is: ❑ feet ❑ meters ❑ above or ❑ below the HAG. b) Top of bottom floor(including basement, crawlspace, or enclosure)is: ❑ feet ❑ meters ❑ above or ❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 1-2 of Instructions),the next higher floor(C2.b in applicable Building Diagram)of the building is: ❑ feet ❑ meters ❑ above or ❑ below the HAG. E3. Attached garage(top of slab) is: ❑ feet ❑ meters ❑ above or ❑ below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is: ❑ feet ❑ meters ❑ above or ❑ below the HAG. E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown The local official must certify this information in Section G. SECTION F—PROPERTY OWNER(OR OWNER'S AUTHORIZED REPRESENTATIVE)CERTIFICATION The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A(without BFE)or Zone AO must sign here. The statements in Sections A, B, and E are correct to the best of my knowledge ❑ Check here if attachments and describe in the Comments area. Property Owner or Owner's Authorized Representative Name: Address: City: State: ZIP Code: Signature: Date: Telephone: Ext.: Email: Comments: FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 4 of 19 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 111 CROWELL ROAD Policy Number: City: WEST YARMOUTH State: MA ZIP Code: 02673 Company NAIC Number: SECTION G—COMMUNITY INFORMATION (RECOMMENDED FOR COMMUNITY OFFICIAL COMPLETION) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Section A, B, C, E, G, or H of this Elevation Certificate. Complete the applicable item(s)and sign below when: G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by state law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2.a. ❑ A local official completed Section E for a building located in Zone A(without a BFE),Zone AO, or Zone AR/AO, or when item E5 is completed for a building located in Zone AO. G2.b. ❑ A local official completed Section H for insurance purposes. G3. ❑ In the Comments area of Section G, the local official describes specific corrections to the information in Sections A, B, E and H. G4. ❑ The following information(Items G5—G11) is provided for community floodplain management purposes. G5. Permit Number: G6. Date Permit Issued: G7. Date Certificate of Compliance/Occupancy Issued: G8. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement G9.a. Elevation of as-built lowest floor(including basement)of the building: ❑ feet ❑ meters Datum: G9.b. Elevation of bottom of as-built lowest horizontal structural member: ❑ feet ❑ meters Datum: G10.a. BFE(or depth in Zone AO)of flooding at the building site: ❑ feet ❑ meters Datum: G10.b. Community's minimum elevation(or depth in Zone AO) requirement for the lowest floor or lowest horizontal structural member: ❑ feet ❑ meters Datum: G11. Variance issued? ❑Yes ❑ No If yes, attach documentation and describe in the Comments area. The local official who provides information in Section G must sign here. I have completed the information in Section G and certify that it is correct to the best of my knowledge. If applicable, I have also provided specific corrections in the Comments area of this section. Local Official's Name: Title: NFIP Community Name: Telephone: Ext.: Email: Address: City: State: ZIP Code: Signature: Date: Comments(including type of equipment and location, per C2.e; description of any attachments; and corrections to specific information in Sections A, B, D, E, or H): FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 5 of 19 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 111 CROWELL ROAD Policy Number. City: WEST YARMOUTH State: MA ZIP Code: 02673 Company NAIC 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 IA, 1B, 3,and 5-9.Top of bottom ❑ feet ❑ meters ❑ above the LAG 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 ❑ meters ❑ above the LAG 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? ❑ Yes ❑ No 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. ❑ Check 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: Signature: Date: Telephone: Ext.: Email: Comments: FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 6 of 19 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 111 CROWELL ROAD Policy Number: City: WEST YARMOUTH State: MA ZIP Code: 02673 Company NAIC 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. M a' It 1:"' 0 —1 - _ ' • t L—_______-_,, ---- ,_, ri , :'."'..,.. • t l�, r • t7 w S Photo One Photo One Caption: FRONT/STREET VIEW Clear Photo One rel ,,., _. II . N. \ - !: r • 4 - - t`Tt • __ .I mil isilimiiiir- '. mein ` „�.. a Photo Two Photo Two Caption: SIDE VIEW Clear Photo Two FEMA Form FF-206-FY-22-152(formerly 086-0-33)(10/22) Page 7 of 19 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 111 CROWELL ROAD Policy Number: City: WEST YARMOUTH State: MA ZIP Code 02673 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. : i ir _,`,_1 • :� • !► - _ '► . t ," iiliii.� A-1 3 �IIIII{I.�� • ' yl' P. • • AWL �_ e I .�,,. -w }, - a .• ,te - - 'asp }• w .''.. s . '*.r.;�r gym.". Photo Three Photo Three Caption: REAR AND SIDE VIEW Clear Photo Three re� -i' 11111 ,, '', li II 1 p . 1 i Photo Four Photo Four Caption: WALKOUT WALLS &ADJACENT GRADE TO BE RAISED Clear Photo Four FEMA Form FF-206-FY-22-152 (formerly 086-0-33) (10/22) Page 8 of 19 DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 COMMUNITY ACKNOWLEDGMENT FORM Expires February 28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.38 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security, Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form must be completed for requests involving the existing or proposed placement of fill(complete Section A)OR to provide acknowledgment of this request to remove a property from the SFHA which was previously located within the regulatory floodway(complete Section B). This form must be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number and the subject property address must appear in the spaces provided below. Incomplete submissions will result in processing delays.Please refer to the MT-1 instructions for additional information about this form. Community Number: 250015 Property Name or Address: 111 Crowell Road A. REQUESTS INVOLVING THE PLACEMENT OF FILL As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter of Map Revision Based on Fill(LOMR-F)or Conditional LOMR-F request. Based upon the community's review,we find the completed or proposed project meets or is designed to meet all of the community floodplain management requirements,including the requirement that no fill be placed in the regulatory floodway,and that all necessary Federal,State,and local permits have been,or in the case of a Conditional LOMR-F,will be obtained. For Conditional LOMR-F requests,the applicant has or will document Endangered Species Act(ESA)compliance to FEMA prior to issuance of the Conditional LOMR-F determination. For LOMR-F requests, I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved independently of FEMA's process.Section 9 of the ESA prohibits anyone from"taking"or harming an endangered species. If an action might harm an endangered species,a permit is required from U.S.Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA. For actions authorized,funded,or being carried out by Federal or State agencies,documentation from the agency showing its compliance with Section 7(a)(2)of the ESA will be submitted.In addition,we have determined that the land and any existing or proposed structures to be removed from the SFHA are or will be reasonably safe from flooding as defined in 44CFR 65.2(c),and that we have available upon request by DHS-FEMA,all analyses and documentation used to make this determination. For LOMR-F requests,we understand that this request is being forwarded to DHS- FEMA for a possible map revision. Community Comments: Community Official's Name and Title: (Please Print or Type) Teleph ne No.: � -r it gvi Lr/// - 'fl/d���% s�� s 4,1 z z ;/ Community Name: Community Offici ' uired) Date: Yarmouth 6 4---/ r B. PROPERTY LOCATED WITHIN THE REGULATORY FLOODWAY As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this request for a LOMA. We understand that this request is being forwarded to DHS-FEMA to determine if this property has been inadvertently included in the regulatory floodway. We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway. We find that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements. Community Comments: Community Official's Name and Title: (Please Print or Type) Telephone No.: Community Name: Community Official's Signature(required): Date: DHS-FEMA Form 086-0-26B,FEB 11 Community Acknowledgment Form MT-1 Form 3 Page 1 of 1 FEDERAL EMERGENCY MANAGEMENT AGENCY PAYMENT INFORMATION FORM Community Name:Yarmouth Project Identifier: 111 Crowell Road, West Yarmouth THIS FORM MUST BE MAILED,ALONG WITH THE APPROPRIATE FEE,TO THE ADDRESS BELOW OR FAXED TO THE FAX NUMBER BELOW. Please make check or money order payable to the National Flood Insurance Program. Type of Request: LOMC Clearinghouse IMI MT-1 application 847 South Pickett Street n MT-2 application Alexandria,VA 22304-4605 Attn.: LOMC Manager FEMA Project Library ❑ EDR application 847 South Pickett Street Alexandria,VA 22304-4605 FAX(703) 212-4090 Request No.(if known): Check No.: Amount: $500 U INITIAL FEE* n FINAL FEE fl FEE BALANCE** n MASTER CARD n VISA n CHECK n MONEY ORDER *Note: Check only for EDR and/or Alluvial Fan requests(as appropriate). **Note:Check only if submitting a corrected fee for an ongoing request. COMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD CARD NUMBER EXP. DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Year Date Signature NAME(AS IT APPEARS ON CARD): (please print or type) ADDRESS: (for your credit card receipt-please print or type) DAYTIME PHONE: FEMA Form 81-107 Payment Information Form In addition to this form(MT-1 Form 1),please complete the checklist below. ALL requests must include one copy of the following: ■❑ Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted(property inadvertently located in the NFIP regulatory floodway will require Section B of MT-1 Form 3) ■❑ Copy of the Subdivision Plat Map for the property(with recordation data and stamp of the Recorder's Office) OR ■❑ Copy of the Property Deed(with recordation data and stamp of the Recorder's Office),accompanied by a tax assessor's map or other certified map showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street intersection that is shown on the FIRM panel. ■❑ Form 2—Elevation Form. If the request is to remove the structure,and an Elevation Certificate has already been completed for this property,it may be submitted in lieu of Form 2. If the request is to remove the entire legally recorded property,or a portion thereof,the lowest lot elevation must be provided on Form 2. ■❑ Please include a map scale and North arrow on all maps submitted. For LOMR-Fs and CLOMR-Fs,the following must be submitted in addition to the items listed above: ❑ Form 3—Community Acknowledgment Form For CLOMR-Fs,the following must be submitted in addition to the items listed above: ■❑Documented ESA compliance,which may include a copy of an Incidental Take Permit,an Incidental Take Statement,a"not likely to adversely affect" determination from the National Marine Fisheries Service(NMFS)or the U.S.Fish and Wildlife Service(USFWS),or an official letter from NMFS or USFWS concurring that the project has"No Effect"on proposed or listed species or designated critical habitat.Please refer to the MT-1 instructions for additional information. Please do not submit original documents. Please retain a copy of all submitted documents for your records. DHS-FEMA encourages the submission of all required data in a digital format(e.g.scanned documents and images on Compact Disc[CD]). Digital submissions help to further DHS-FEMA's Digital Vision and also may facilitate the processing of your request. Incomplete submissions will result in processing delays.For additional information regarding this form,including where to obtain the supporting documents listed above,please refer to the MT-1 Form Instructions located at-:'p://www.fema.gov/plan/prevent/fhm/dl_mt-1.shtm. Processing Fee(see instructions for appropriate mailing address;or visit http://www.fema.gov/fhm/frm_fees.shtm for the most current fee schedule) Revised fee schedules are published periodically,but no more than once annually,as noted in the Federal Register. Please note: single/multiple lot(s)/structure(s) LOMAs are fee exempt. The current review and processing fees are listed below: Check the fee that applies to your request: ❑$325(single lot/structure LOMR-F following a CLOMR-F) ❑$425(single lot/structure LOMR-F) ■❑$500(single lot/structure CLOMA or CLOMR-F) ❑$700(multiple lot/structure LOMR-F following a CLOMR-F,or multiple lot/structure CLOMA) ❑$800(multiple lot/structure LOMR-F or CLOMR-F) Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to: National Flood Insurance Program. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Applicant's Name(required): Kieran J. Healy Company(if applicable): BSC Group, Inc. Mailing Address(required): Daytime Telephone No.(required): (774) 487-0598 349 Route 28,West Yarmouth,MA 02673 E-Mail Address(optional): ■❑By checking here you may receive Fax No.(optional): correspondence electronically at the email address provided): Date(required) 06/04/2025 Signature of Applicant(required) DHS-FEMA Form 086-0-26,FEB 11 Property Information Form MT-1 Form 1 Page 2 of 2 DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 PROPERTY INFORMATION FORM Expires February 28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.63 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security,Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form may be completed by the property owner,property owner's agent,licensed land surveyor,or registered professional engineer to support a request for a Letter of Map Amendment(LOMA),Conditional Letter of Map Amendment(CLOMA),Letter of Map Revision Based on Fill(LOMR-F),or Conditional Letter of Map Revision Based on Fill(CLOMR-F)for existing or proposed,single or multiple lots/structures. In order to process your request,all information on this form must be completed in its entirety,unless stated as optional. Incomplete submissions will result in processing delays. Please check the item below that describes your request: ❑ LOMA A letter from DHS-FEMA stating that an existing structure or parcel of land that has not been elevated by fill(natural grade)would not be inundated by the base flood. ❑ CLOMA A letter from DHS-FEMA stating that a proposed structure that is not to be elevated by fill(natural grade)would not be inundated by the base flood if built as proposed. ❑■ LOMR-F A letter from DHS-FEMA stating that an existing structure or parcel of land that has been elevated by fill would not be inundated by the base flood. A letter from DHS-FEMA stating that a parcel of land or proposed structure that will be elevated by fill ❑■ CLOMR-F would not be inundated by the base flood if fill is placed on the parcel as proposed or the structure is built as proposed. Fill is defined as material from any source(including the subject property)placed that raises the ground to or above the Base Flood Elevation(BFE). The common construction practice of removing unsuitable existing material(topsoil)and backfilling with select structural material is not considered the placement of fill if the practice does not alter the existing(natural grade)elevation,which is at or above the BFE. Fill that is placed before the date of the first National Flood Insurance Program(NFIP)map showing the area in a Special Flood Hazard Area(SFHA)is considered natural grade. Has fill been placed on your property to raise ground that was previously below the BFE? ❑ Yes ■I No If yes,when was fill placed? mm/dd/yyyy Will fill be placed on your property to raise ground that is below the BFE? [1 Yes* E No If yes,when will fill be placed? 09/16/2025 m m/dd/yyyy *If yes, Endangered Species Act(ESA)compliance must be documented to FEMA prior to issuance of the CLOMR-F determination(please refer page 4 to the MT-1 instructions). 1. Street Address of the Property(if request is for multiple structures or units,please attach additional sheet referencing each address and enter street names below): 111 Crowell Road, West Yarmouth, MA 02673 2. Legal description of Property(Lot,Block,Subdivision or abbreviated description from the Deed): Lot 3A on plan 336-10, title in deed 31370-314 and assessors 17-77 3. Are you requesting that a flood zone determination be completed for(check one): Q Structures on the property? What are the dates of construction? (MM/YYYY) E A portion of land within the bounds of the property?(A certified metes and bounds description and map of the area to be removed,certified by a licensed land surveyor or registered professional engineer,are required.For the preferred format of metes and bounds descriptions, please refer to the MT-1 Form 1 Instructions.) ❑ The entire legally recorded property? 4. Is this request for a(check one): Q Single structure ❑ Single lot ❑ Multiple structures(How many structures are involved in your request?List the number: ❑ Multiple lots(How many lots are involved in your request?List the number: MT-1 Form 1 Page 1 of 2 OHS-FEMA Form 086-0-26, FEB 11 Property Information Form Continued from Page 1. Lowest Adjacent Address Lot Number Block Number Lowest Lot Grade To Base Flood BFE Source Elevation* Structure Elevation This certification is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Certifier's Name: License No.: Expiration Date: Company Name: Telephone No.: Email: Fax No. Signature: Date: *For requests involving a portion of property,include the lowest ground elevation within the metes and bounds description. Seal(Optional) Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a determination will be issued for the structure only. DHS-FEMA Form 086-0-26A,FEB 11 Elevation Form MT-1 Form 2 Page 2 of 2 DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 ELEVATION FORM Expires February 28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.25 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security,Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS-FEMA National Flood Insurance Program(NFIP)Elevation Certificate may be submitted in lieu of this form for single structure requests. For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area(SFHA),submit the lowest adjacent grade(the lowest ground touching the structure),including an attached deck or garage.For requests to remove an entire parcel of land from the SFHA,provide the lowest lot elevation; or,if the request involves an area described by metes and bounds,provide the lowest elevation within the metes and bounds description.All measurements are to be rounded to nearest tenth of a foot. In order to process your request,all information on this form must be completed in its entirety. Incomplete submissions will result in processing delays. ,1 1. NFIP Community Number:250015 Property Name or Address:1 1 1 Crowell Road 2. Are the elevations listed below based on ❑existing or ■❑proposed conditions? (Check one) 3. For the existing or proposed structures listed below,what are the types of construction? (check all that apply) ❑crawl space❑slab on grade ❑■ basement/enclosure ❑other(explain) 4. Has DHS-FEMA identified this area as subject to land subsidence or uplift?(see instructions) ❑Yes ❑■ No If yes,what is the date of the current re-leveling? / (month/year) 5. What is the elevation datum? ❑ NGVD 29 ❑■ NAVD 88 ❑Other(explain) If any of the elevations listed below were computed using a datum different than the datum used for the effective Flood Insurance Rate Map (FIRM)(e.g.,NGVD 29 or NAVD 88),what was the conversion factor? Local Elevation+/-ft.=FIRM Datum 6. Please provide the Latitude and Longitude of the most upstream edge of the structure(in decimal degrees to the nearest fifth decimal place): Indicate Datum: ❑WGS84 ❑ NAD83 ❑ NAD27 Lat. Long. Please provide the Latitude and Longitude of the most upstream edge of the property(in decimal degrees to the nearest fifth decimal place): Indicate Datum: ❑WGS84 ❑ NAD83 ❑ NAD27 Lat. Long. Lowest Address Lot Number Block Lowest Lot Adjacent Base Flood BFE Source Number Elevation* Grade To Elevation Structure 111 Crowell Road 3A 11.2 12.2/6.6 10.8 This certification is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Certifier's Name: License No.: Expiration Date:06/30/2026 Kieran J.Healy 48135 Company Name: Telephone No.: BSC Group Inc. 774-487-0298 Email: Fax No. khealy@bscgroup.com Signature: Date: 06/04/2025 *For requests involving a portion of property,include the lowest ground elevation within the metes and bounds description. Seal (optional) Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a determination will be issued for the structure only. DHS-FEMA Form 086-0-26A,FEB 11 Elevation Form MT-1 Form 2 Page 1 of 2