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Continued from Page 1. <br /> loweLowest Adjacent Base FIOOtl <br /> st Lot <br /> Address Lot Number Block Number Elevation Grade re Elevation BRE Source <br /> Structure <br /> Th.,omuf¢ation is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized bylaw to certify elevation <br /> 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 <br /> by fine or imprisonment under Title 18 of the United States Code,Section 10D1. <br /> Certifies Name: License No.: Expiration Date', <br /> Company Name: Telephone No.'. <br /> Email: Fax No. <br /> Signature: Date: <br /> 'for requests Involving a portion of property,include the lowest ground elevation within <br /> the metes and bounds description. Seal(optional) <br /> Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a <br /> determination will be Issued for the structure only. <br /> @IS-FEMA Form 0060-26A,FEB 11 Elevation Form MT-1 Farm 2 Page 2 oft <br />