HomeMy WebLinkAbout22115 Clearwood Ct - Corrected
Memo of Review for Correctness and Completion
The attached FEMA Elevation Certificate has been reviewed by this office.
The items noted below are not correct on the attached form and should read as entered on this page.
SECTION A – PROPERTY INFORMATION
A1. Building Owner's Name:
A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.:
City: State: ZIP Code:
A3. Property Description (e.g., Lot and Block Numbers or Legal Description) and/or Tax Parcel Number:
A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.):
A5. Latitude/Longitude: Lat. Long. 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:
A8. For a building with a crawlspace or enclosure(s):
a) Square footage of crawlspace or enclosure(s): 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: Engineered flood openings:
d) Total net open area of non-engineered flood openings in A8.c: 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): 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: 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.
22115 Clearwood Ct
CA 95014Cupertino
Page 2 of 2
SECTION B – FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1.a. NFIP Community Name: B1.b. NFIP Community Identification Number:
B2. County Name: B3. State: B4. Map/Panel No.: B5. Suffix:
B6. FIRM Index Date: B7. FIRM Panel Effective/Revised Date:
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:
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
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.
f) Lowest Adjacent Grade (LAG) next to building: Natural Finished
g) Highest Adjacent Grade (HAG) next to building: Natural Finished
SECTION G – COMMUNITY INFORMATION (RECOMMENDED FOR COMMUNITY OFFICIAL COMPLETION)
G8. This permit has been issued for: New Construction Substantial Improvement
G11. Variance Issued? Yes No If yes, attach documentation and describe in the Comments area.
ADDITIONAL INFORMATION
Additional or corrected information from Sections C, D, G and H that are allowed by the local official can be included in the Comments below.
Be sure all corrections are adequately explained. Additional or corrected elevations in Section C are not to be included on this form.
Local Official’s Name Title
Date
Comments
City of Cupertino
Chad Mosley Director of Public Works & City Engineer
8-20-25
Fields G8 & G11 and local offical information under Section G were not completed on the original EC.Local Official Email: chadm@cupertino.govLocal Official Address: 10300 Torre Ave, Cupertino, CA 95014
National Flood Insurance Program
Elevation
Certificate
and Instructions
2023 EDITION
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FEMA
U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
ELEVATION CERTIFICATE AND INSTRUCTIONS
PAPERWORK REDUCTION ACT NOTICE
0MB Control No. 1660-0008
Expiration Date: 06/30/2026
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 0MB 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.
PRIVACY ACT STATEMENT
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.
PURPOSE 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 for a 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 flood proofing. 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 flood proofed 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 AB 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) (8/23) Form Page 1 of 8
Form Instructions U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
0MB Control No. 1660-0008
Expiration Date: 06/30/2026
ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
Copy all pages of this Elevation Certificate and all attachments for (1) communitv official (2) insurance agent/company and (3) building owner '
SECTION A - PROPERTY INFORMATION FOR INSURANCE COMPANY USE
A1. Building Owner's Name: Policy Number:
l'\L.. ou11amg ->treec l'\aaress \incIuaIng /'\pc., um1, ;::,une, ana,or 0109. NO.J or r--.v. ~ouce ana oox Company NAIC Number: f\l,...
City: State: ZIP Code:
A3. Property Description (e.g., Lot and Block Numbers or Legal Description) and/or Tax Parcel Number:
A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.):
AS. Latitude/Longitude: Lat. Long. Horiz. Datum: ONAD 1927 0NAD 1983 0WGS84
A6. Attach at least two and when possible four clear color photographs (one for each side) of the building (see Form pages 7 and 8).
A7. Buildin!l DiaQram Number:
A8. For a building with a crawlspace or enclosure(s):
a) Square footage of crawlspace or enclosure(s): sq. ft.
b} Is there at least one permanent flood opening on two different sides of each enclosed area? OYes 0No ON/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: Engineered flood openings:
d} Total net open area of non-engineered flood openings in A8.c: 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): 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? 0Yes 0No ON/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
B1 .a. NFIP Community Name: B1 .b. NFIP Community Identification Number:
B2. County Name: B3. State: B4. Map/Panel No.: BS. Suffix: ---
B6. FIRM Index Date: B7. FIRM Panel Effective/Revised Date:
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:
Ci:,~ 0FIRM Or.nmm, 1nih1 n<>t<>rmin<>rl Cother:
B11. Indicate elevation datum used for BFE in Item B9: 0NGVD 1929 ONA\/n 1qRR OOther/Source:
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 0Yes 0No
Designation 0CBRS COPA
B13. Is the buildinq located seaward of the Limit of Moderate Wave Action (LiMWA)? OYes 0No
FEMA Form FF-206-FY-22-1 S2 (formerly 086-0-33) (8/23) Form Page 2 of 8
CT
CUPERTINO CA 95014
RESIDENTIAL
LOT 78 TRACT #3628 OAKDELL RANCH UNIT NO. 2 BK 177 PG 31 SCCR
3.47
8.58
1
8.58
COUNTY OF SANTA CLARA 060337
SANTA CLARA CA 06085C0208H
05-18-2009
AE 293
X
X
X
Form Instructions ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
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:
SECTION C -BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: OConstruction Drawings* OBuilding Under Construction* OFinished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations -Zones A 1-A30, AE, AH, AO, A (with BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/A 1-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: Vertical Datum:
Indicate elevation datum used for the elevations in items a) through h) below.
ONGVD 1929 QNA\/n 1QRR Cother:
Datum used for building elevations must be the same as that used for the BFE. Conversion factor used? OYes ONo
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): a feet a meters
b} Top of the next higher floor (see Instructions): a feet a meters
c) Bottom of the lowest horizontal structural member (see Instructions): a feet a meters
d) Attached garage (top of slab): a feet a 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): a feet a meters
f) Lowest Adjacent Grade (LAG) next to building: □Natural □Finished a feet a meters
g) Highest Adjacent Grade (HAG) next to building: □Natural □Finished a feet a meters
h) Finished LAG at lowest elevation of attached deck or stairs, including structural
support: a feet a 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? cYes ONo
C Check here if attachments and describe in the Comments area.
Certifier's Name: License Number: Place Seal Here
Title:
Company Name:
Address:
City: State: ZIP Code:
Telephone: Ext.: Email: --
Date:
Copy all pages of this Elevation community official, (2) insurance agenUcompany, 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):
FEMA Form FF-206-FY-22-152 (formerly 086-0-33) (8/23) Form Page 3 of 8
22115 CLEARWOOD CT
CUPERTINO CA 95014
X
400 305.40
X
293.50
293.50
X
X
293.36 X
293.26 XX
294.92 XX
293.26 X
Form Instructions ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
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:
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 E1-E5. For Items E1-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: Oconstruction Drawings* □Building Under Construction* □Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
E1. 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: D feet D meters Oabove or Cbelow the HAG.
b) Top of bottom floor (including basement,
crawlspace, or enclosure) is: D feet a meters Cabove or Cbelow 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: D feet a meters Cabove or Cbelow the HAG.
E3. Attached garage (top of slab) is: D feet a meters Cabove or Cbelow the HAG.
E4. Top of platform of machinery and/or equipment
servicing the building is: D feet a meters Cabove or Cbelow the HAG.
ES. 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? CYes 0 No 0 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
CCheck here if attachments and describe in the Comments area.
Property Owner or Owner's Authorized Representative Name:
Address:
City: State: ZIP Code:
Telephone: Ext.: Email: --
Date:
Comments:
FEMA Form FF-206-FY-22-152 (formerly 086-0-33) (8/23) Form Page 4 of 8
22115 CLEARWOOD CT
CUPERTINO CA 95014
Form Instructions ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
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:
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 Hof 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,
Cengineer, 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. ~ 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. CA local official completed Section H for insurance purposes.
G3. Orn the Comments area of Section G, the local official describes specific corrections to the information in Sections A, B, E and H.
G4. OThe 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:
GB. This permit has been issued for: CNew Construction □Substantial Improvement
G9.a. Elevation of as-built lowest floor (including basement) of the
building: Cfeet om.ot10rc:: Datum:
G9.b. Elevation of bottom of as-built lowest horizontal structural
member: Cfeet Qm,:,l,:,rc: Datum:
G10.a. BFE (or depth in Zone AO) of flooding at the building site: Cfeet ameit,m: Datum:
G10.b. Community's minimum elevation (or depth in Zone AO)
requirement for the lowest floor or lowest horizontal structural
member: Cfeet am10t1:uc:: Datum:
G11. Variance issued? CYes CNn 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:
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) (8/23) Form Page 5 of 8
22115 CLEARWOOD CT
CUPERTINO CA 95014
Form Instructions ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
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:
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 5-8. Top of bottom Oeet 0mAt<!ri:: 0::ihnvA th<! I Ar.
floor (include above-grade floors only for buildings with
crawlspaces or enclosure floors) is:
b) For Building Diagrams 2A, 2B, 4, and 6-9. Top of next Oeet om .. t<>rc: 0::ihnv<> th<> I Ar.
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?
0Yes 0Nn
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 Hare 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.
0check here if attachments are provided (includinQ reouired photos) and describe each attachment in the Comments area.
Property Owner or Owner's Authorized Representative Name:
Address:
City: State: ZIP Code:
Telephone: Ext.: Email: --
Date:
Comments:
FEMA Form FF-206-FY-22-152 (formerly 086-0-33) (8/23) Form Page 6 of 8
22115 CLEARWOOD CT
CUPERTINO CA 95401
Form Instructions ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
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
Policy Number: _______ _
City: State: ----ZIP Code: ------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 AB and A9.
Photo One
Photo One Caption: I Clear Photo One I
Photo Two
Photo Two Caption: I Clear Photo Two I
FEMA Form FF-206-FY-22-152 (formerly 086-0-33) (8/23) Form Page 7 of 8
22115 CLEARWOOD CT
CUPERTINO CA 95014
front view
Rear @ rightside view
Form Instructions ELEVATION CERTIFICATE
IMPORTANT: MUST FOLLOW THE INSTRUCTIONS ON INSTRUCTION PAGES 1-11
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: Clear Photo Th-;;;I
Photo Four
Photo Four Caption: j Clear Photo Four I
FEMA Form FF-206-FY-22-152 (formerly 086-0-33) (8/23) Form Page 8 of 8
22115 CLEARWOOD CT
CUPERTINO CA 95014
rear at left side view
rear to left side view