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ELEVATION CERTIFICATE OMB No. 1660-0008 Expiration Date: November 30,2022 IMPORTANT: In these spaces,copy the corresponding Information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No. Policy Number: 6463 Midtown Rd City State ZIP Code Company NAIC Number Siren Wisconsin 54872 SECTION G—COMMUNITY INFORMATION(OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C(or E),and G of this Elevation Certificate. Complete the applicable item(s)and sign below. Check the measurement used in Items G8—G10. In Puerto Rico only,enter meters. G1. 0 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 law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2 ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE) or Zone AO. G3. ❑x The following information(Items G4—G10)is provided for community floodplain management purposes. G4. Permit Number G5. Date Permit Issued G6. Date Certificate of Compliance/Occupancy Issued LUP-23-14 02-07-2023 G7. This permit has been issued for: ❑x New Construction ❑ Substantial Improvement G8. Elevation of as-built lowest floor(including basement) of the building: ❑feet ❑ meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑ meters Datum G10. Community's design flood elevation: ❑ feet ❑ meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments(including type of equipment and location,per C2(e), if applicable) ❑ Check here if attachments. FEMA Form 086-0-33(12/19) Replaces all previous editions. Form Page 4 of 6