1455 Begonia Street WELL-SEPTIC 09.08.2011City of Atlantic Beach • 800 Seminole Road • Atlantic Beach, Florida 32233-5445
Phone: (904) 247-5800 • Fax (904) 247-5805 • http://www.coab.us
APPLICATION FOR ASSISTANCE
WITH CONVERSION FROM
WELL AND SEPTIC TANK TO CITY WATER AND SEWER
FY 2011-20-12 COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM
The information requested on this form is required in order to determine your eligibility to participate in this
program. (These funds may be available to homeowners whose incomes are within low and moderate levels
based upon family size and as established by HUD Section 8 Income Limits.) Please answer all questions,
and provide copies of all required documents. (Your information is considered confidential.) Funds for this
program are available only to owner -occupied homes. In the case of a duplex or two-family dwelling, the
property owner must live full-time in one of the two units as documented by a valid homestead exemption.)
Grant funds are limited, and applicants are selected based upon most urgent and serious need and
availability of funds.
DATE:
1. Homeowner Name(s): `\y 4 E , Ei vrn
2. Address of Home: '01
3. Telephone Number: (day) 5 A(V� (night)
4. Is the person completing this application the Head of Household? N yes ❑ no ❑ female U male
5. How many family members live in this house?
Ca
fel
Are there people living in this house with disabilities or special needs? ® yes ❑ no
explain
Number and age of persons living in the household in addition to Head of Household.
Ages 0 — 5 years old Male
Ages 6 —17 years old Male
Ages 18 — 39 years old Male
Ages 40 — 64 years old ./ Male ✓
Ages 65 and older Male
8. Water supply is provided by: ❑City Water Private Well
9. Does septic system work properly? R] Yes ❑ No If no, please explain.
Page 1 of 3
Female
Female
Female
Female
Female
If yes, please
S et %
Other
INCOME VERIFICATION FORM
PART I. (To be filled out by the person (employee) completing this application.)
Applicant / Employee name:
Address: T.0`,7 tLA �f
Social Security Number: ,�"4� / 17 -- L 6 3
I hereby authorize release of my income information to the City of Atlantic Beach for
the purpose of applying for participation in the septic to sewer conversion funding
assistance Progr m, which is funded by a Community Development Block Grant.
Sig of wner D e
PART II. (To be filled out by employer, Social Security Administration or HRS.)
Please provide the following information and return to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
Applicant / Employees Name:
Gross Monthly Income: $,
Is employment: ❑ permanent ❑ part-time ❑ temporary
Employer Name:
Address:
Telephone:
Name and title of person providing this information. Date
Page 3 of 3
10.
Does your plumbing work properly? Yes ❑ No
If no, please explain.
11. Is there hot and cold running water in your house? ZjYes ❑ No
12. Do you have a complete kitchen with running water, a refrigerator and cooking facilities? �p j
13. How many persons are in your family and living at this address?
14. Federal regulations require that we keep track of certain demographic information and the type of
households being served. Please check the appropriate box below.
White, Not Hispanic
❑ African-American, Not Hispanic
❑ American Indian or Native Alaskan
❑ Hispanic
❑ Asian or Pacific Islander
❑ Female Head of Household
❑ Other
15. What is the total annual income (before taxes) of your household?
� S.v
16. Are you on a fixed income such as Social Security, SSI or retirement? `) Yes ❑ No
17. What are your sources of income? NAVu
18. Do you own this home? 5 f Yes ❑ No
If you own your home, please provide a copy of your deed and a recent water or electric bill which shows that
e at this address. If u rent your me, please provide a copy of the lease.
2 4
Signa f 4wne Date
If you have any questions about this application or need any assistance preparing
the application, please contact the City of Atlantic Beach at (904) 247-5817.
The following Income Verification Form must also be completed and mailed or
delivered to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
Please provide the time of day and day of the week (Monday through Friday) when it would be
most convenient to make arrangements for a City Inspector to meet with you, and the phone
number where you wish to be called. �- �� jeo 0 •�,?TT� � �
Page 2 of 3
E
°
LL
�40
Department of the Treasury—Internal Revenue Service O 0
U.S. Individual Income Tax Return
(99) IRS Use Only—Do not write or staple in this space.
P
For the year Jan. 1—Dec. 31. 2010, or other tax year beginning 2010, ending 20 OMB No. 1545-0074
Name, R
Your first name and initial Last name
Your social security number
Address, N
Roy E Humphrey
508-68-6035
and SSN T
if a joint return, spouse's first name and initial Last name
Spouse's social security number
C
Linda D Humphrey
262-33-1163
See separate E
instructions.
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no. Make sure the SSN(s) above
A
1455 Begonia St
It and on line 6c are correct.
R
L
City, town or post office, state, and ZIP code. If you have a foreign address, see instructions. Checking a box below will not
Y
Presidential 11
Atlantic Beach FL 32233
change your tax or refund.
Election Campaign
► Check here if you, or your spouse if filing jointly, want $3 to go to this
fund . P. ❑ You ❑ Spouse
Filing Status
1 ❑ Single 4
❑ Head of household (with qualifying person). (See instructions.) If
13
2 ® Married filing jointly (even if only one had income)
the qualifying person is a child but not your dependent, enter this
Check only one
3 ❑ Married filing separately. Enter spouse's SSN above
child's name here. ►
box.
and full name here. ► 5
❑ Qualifying widow(er) with dependent child
Exemptions
If more than four
dependents, see
instntctinnc and
6a ® Yourself. If someone can claim you as a dependent, do not check box 6a . . . . .
b ® Spouse
c Dependents: (2) Dependent's (3) Dependent's (4) V if child under age 17
(t) First name Last name social security number relationship to you qualifying ffor child tax credit
P9 )
Boxes checked
on 6a and 6b
No. of children
on 6c who:
• lived with you
• did not live with
you due to divorce
or separation
(see instructions)
Dependents on 6c
not entered above
2
check here ► ❑
I I
I U
Add
Total number of exemptions claimed
numbers on
lines above 10-
EJd
Income
Attach Form(s)
W-2 here. Also
attach Forms
W -2G and
1099-R if tax
was withheld.
If you did not
get a W-2,
see page 20.
Enclose, but do
not attach, any
payment. Also,
please use
Form 1040-V.
7
8a
b
9a
b
10
11
12
13
14
15a
16a
17
18
19
20a
21
22
Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . .
Taxable interest. Attach Schedule B if required . . . . . . . . . .
Tax-exempt interest. Do not include on line 8a . . . 8b
Ordinary dividends. Attach Schedule B if required . . . . . . . . .
Qualified dividends . . . . . . . . . . . 9b
Taxable refunds, credits, or offsets of state and local income taxes . . . . . .
Alimony received . . . . . . . . . . . . . . . . . . . . .
Business income or (loss). Attach Schedule C or C -EZ . . . . . . . . .
Capital gain or (loss). Attach Schedule D if required. If not required, check here ► ❑
Other gains or (losses). Attach Form 4797 . . . . . . . . . .
IRA distributions 15a b Taxable amount
Pensions and annuities I 16a I I I b Taxable amount . . .
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . .
Unemployment compensation . . . . . . . . . . . . .
Social security benefits 120a I 17,322. I I b Taxable amount . . .
Other income. List type and amount
Combine the amounts in the far right column for lines 7 through 21. This is your total income ►
7
8a
9a
10
11
12
13
0.
14
15b
16b
20,420a
17
18
19
13,448.
20b
4,665.
21
22
38,533.
Adjusted
Gross
Income
23
24
25
26
27
28
29
30
31a
32
33
34
35
36
37
Educator expenses . . . . . . . . . .
Certain business expenses of reservists, performing artists, and
fee -basis government officials. Attach Form 2106 or 2106 -EZ
Health savings account deduction. Attach Form 8889
Moving expenses. Attach Form 3903 . . . . . .
One-half of self-employment tax. Attach Schedule SE
Self-employed SEP, SIMPLE, and qualified plans
Self-employed health insurance deduction . . . .
Penalty on early withdrawal of savings . . . . . .
Alimonypaid b Recipient's SSN► 524-52-7152
IRA deduction . . . . . . . . . . . . .
Student loan interest deduction . . . . . . . .
Tuition and fees. Attach Form 8917 . . . . . . .
Domestic production activities deduction. Attach Form 8903
Add lines 23 through 31 a and 32 through 35 . . . .
Subtract line 36 from line 22. This is your adjusted gross
23
36
1,200.
24
25
26
27
28
29
30
31a 1,200.
32
33
34
35
. . . . . . . . .
income ►
37
37,333 .
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. BAA FfvOyfimITWA OR* Form IU4U (2010)
Form 1040 (2010)
508-68-6035 Paget
Tax and 38 Amount from line 37 (adjusted gross income) . . . . . . . . . .
❑ You were born before January 2, 1946, ❑ Blind. 1 Total boxes
39a Check j l J
Credits
if: E] Spouse was born before January 2, 1946, ❑ Blind. checked ► 39a
b If your spouse itemizes on a separate return or you were a dual -status alien, check here I" 39b❑
40 Itemized deductions (from Schedule A) or your standard deduction (see instructions) . .
41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . .
42 Exemptions. Multiply $3,650 by the number on line 6d . . . . . . . . . . . .
43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . .
44 Tax (see instructions). Check if any tax Is from: a ❑ Form(s) 8814 b ❑ Form 4972.
45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . .
46 Add lines 44 and 45 . . . . . . . . . . . . . . . . . . . ►
47 Foreign tax credit. Attach Form 1116 if required . . . . 47
48 Credit for child and dependent care expenses. Attach Form 2441 48
49 Education credits from Form 8863, line 23 . . . . . 49 535.
50 Retirement savings contributions credit. Attach Form 8880 50
51 Child tax credit (see instructions) . . . . . . . . 51
52 Residential energy credits. Attach Form 5695 . . . . 52
53 Other credits from Form: a ❑ 3800 b ❑ 8801 c ❑ 53
54 Add lines 47 through 53. These are your total credits . . . . . . . . . . . .
55 Subtract line 54 from line 46. If line 54 is more than line 46, enter -0- . . . . . ►
38
17,111,
40
11,400.
41
25,933.
42
7,300.
43
18,633.
44
1 f 956 .
45
46
1,956.
54
535.
55
1,421.
Other 56 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . .
Taxes 57 Unreported social security and Medicare tax from Form: a ❑ 4137 b ❑ 8919
58 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required
59 a ❑ Form(s) W-2, box 9 b ❑ Schedule H c ❑ Form 5405, line 16 . . . .
60 Add lines 55 through 59. This is your total tax ►
56
57
58
59
60
1,421.
Payments 61 Federal income tax withheld from Forms W-2 and 1099 . .
62 2010 estimated tax payments and amount applied from 2009 return
63 Making work pay credit. Attach Schedule M . . . . . . .
If you have a 64a Earned income credit (EIC) . . . .
qualifying
child, attach b Nontaxable combat pay election I 64b
Schedule EIC. 65 Additional child tax credit. Attach Form 8812 . . . . . .
66 American opportunity credit from Form 8863, line 14 . . .
67 First-time homebuyer credit from Form 5405, line 10 . . .
68 Amount paid with request for extension to file . . . . .
69 Excess social security and tier 1 RRTA tax withheld . . . .
70 Credit for federal tax on fuels. Attach Form 4136 . . . .
71 Credits from Form: a ❑ 2439 b ❑ 8839 c ❑ 8801 d ❑ 8885
72 Add lines 61, 62, 63, 64a, and 65 through 71. These are your total
61 2.043.
72
2,400.
62
63 0.
64a
65
66 357.
67
68
69
70
71
payments . ►
Refund 73 If line 72 is more than line 60, subtract line 60 from line 72. This is the amount you overpaid
74a Amount of line 73 you want refunded to you. If Form 8888 is attached, check here . ► ❑
Direct deposit? ► b Routing number 2 5 •• 6 i 0 ; 7 i 4 19 ; 7 4 ': ► c Type: ® Checking ❑ Savings
See ► d Account number 2 0 4 3 25 j 0 7 0 `•. 9 '•: j
instructions.
75 Amount of line 73 you want applied to your 2011 estimated tax ► 75
73
979.
74a
979.
76
Amount 76 Amount you owe. Subtract line 72 from line 60. For details on how to pay, see instructions ►
You Owe 77 Estimated tax penalty see instructions 77
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? ❑ Yes. Complete below. ® No
Designee Designee's Phone Personal identification
name ► no. ► number (PIN) No.
Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief,
Here they are true, correct, d complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Joint return? Aur signature Date Your occupation Daytime phone number
See page 12. A2 ' sabled
Keep a cop �'
for your s nature. If oint return, both mus a e pouse's occupation
records. Qy,� �Q,�N..� �J'Jj'�) unemployed
Paid _. _ .._..._
Preparer
Use Only Firm's name 00, SELF
Firm's address ►
signature ' t I Date
Check Elif PTIN
self-employed
Firm's EIN ►
Phone no.
REVOY16M TIMq pKK Form l U44J (2010)
WELL AND SEPTIC TO WATER / SEWER
CONNECTION AGREEMENT
CITY OF ATLANTIC BEACH,
COUNTY OF DUVAL, STATE OF FLORIDA
ADDRESS AND LEGAL DESCRIPTION OF PROPERTY:
For the value of services received, which may include, abandonment and removal
of existing septic tank, construction of the connection, the sewer tap fee and any
impact fees related to connection of this property to centralized sewer and/or water
services, the undersigned promises to pay, in accordance with the following terms
of this Agreement, to the City of Atlantic Beach, hereinafter known as the Holder
of this Agreement, which is a municipality of the State of Florida, located at 800
Seminole Road, Atlantic Beach, Florida 32233, the principal sum of:
being payable in lawful currency of the United States of America to the Holder at
800 Seminole Road, Atlantic Beach, Florida 32233, or at other such address as the
Holder may specify by written notice to the Maker. S,Aid sum shall bear no interest
and shall be reduced in amount at the rate of one/fifth(1/5th) per year, on each year
anniversary of this Connection Agreement, until reduced to a balance of zero (0)
dollars at the end of five years. Any unforgiven balance shall become immediately
due and payable in the event that the Maker transfers title of ownership or moves
from the premises, which secures this Connection Agreement within the five (5)
year period of time. In the event of the death of the Maker of this Agreement, said
Agreement shall remain in effect and the principal sum that is due shall be reduced
as described above only in the case that an immediate family member, with
qualifying income eligibility, takes residence upon the premises, which secures this
Agreement. In all other cases, and under any other circumstance, any unforgiven
balance shall become immediately due and payable to the Holder.
This Connection Agreement is to be construed and enforced in accordance with the
laws of the State of Florida, and is secured by the real property, located at:
Page 1 of 2
In the event that default is made in the payment of any of the sums as described
and required herein, or in the performance of any agreements contained herein,
then at the option of the Holder of this Rehabilitation Agreement, the remaining
principal balance shall immediately become due to the Holder and collectable
without notice, time being of the essence of this Rehabilitation Agreement
contract, and said remaining principal balance shall bear interest at the highest rate
allowed by applicable law, from such time until paid in full.
Each Maker and Endorser waives presentment, protest, notice of protest and notice
of dishonor and agrees to pay all costs, including reasonable attorney's fees,
whether suit be brought or not, if counsel shall be required after maturity of this
Agreement, and if counsel shall be employed to collect said Agreement or to
protect the security thereof.
Printed Name of Maker:s)
Signature of
Date: �
SWORN AND SUBSCRIBED BEFORE ME THIS DAY OF
STATE OF FLORIDA, COUNTY OF DUVAL
NOTARY'S SIGNATURE
Page 2 of 2
nlog,
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
-�rr
App on Number . . . . . 11-00000504 Date 10/26/11
RE number 171082 -0000 -
NCR OLD ACCOUNT NUMBERS AB12485
Application type description SYSTEM DEVELOPMENT CHARGE RESIDENTIAL
Subdivision Name . . . . . .
Property Use . . . . . . . .
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
Owner Contractor
-
------------------------
-----------------------
HUMPHREY ROY E OWNER
1455 BEGONIA STREET
ATLANTIC BEACH FL 32233
(S
----------------------------------------------------------------------------
Permit . . . . .
. UTIL REV FEE RESIDENTIAL BLDG
Additional desc .
.
Permit Fee . . .
. .00
Plan Check Fee
.00
Issue Date . . .
. 10/26/11
Valuation . . .
. 0
----------------------------------------------------------------------------
Other Fees . . .
. . . . . .
SEWER SDC -SYSTEM DEV CHG
4050.00
WATER CONNECT/METER ONLY
185.00
WATER CROSS CONNECTION
50.00
WATER SDC -SYSTEM DEV CHG
1140.00
----------------------------------------------------------------------------
Fee summary
Charged
Paid Credited
------------------------------
Due
-----------------
Permit Fee Total
----------
.00
.00 .00
.00
Plan Check Total
.00
.00 .00
.00
Other Fee Total
5425.00
5425.00 .00
.00
Grand Total
5425.00
5425.00 .00
.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
Thompson, David
From: tavie85@aol.com
Sent: Tuesday, September 13, 2011 2:00 PM
To: Thompson, David
Subject: Re: Atlantic Beach Request
HELLO SIR. I WAS WONDERING WAT TYPE OF GRANTS DID U HAVE TO HELP ASSIST
WITH THE COST
-----Original Message -----
From: Thompson, David <dthompson@coab.us>
To: TAVIE85 <TAVIE85@AOL.COM>
Sent: Mon, Aug 15, 2011 4:51 pm
Subject: Atlantic Beach Request
Mr. Humphrey,
I received your electronic request for information about connecting to the sewer system.
Please call me when you have a few minutes to talk about it. I may have some grant
funding to assist you with the costs.
David
David E. Thompson, Asst. City Manager
City of Atlantic Beach, Florida
800 Seminole Road
Atlantic Beach, A 32233
(904) 247-5864 Office
(904) 403-4318 Cell
dthompson@coab.us
I
PROPOSAL
1 41
jo
CHRISTY FIRST COAST PLUMBING, INC.
1651 MAYPORT ROAD, ATLANTIC BEACH, FL 32233
247-4419 (Office); 249-4660 (Fax)
CFC056487
PROPOSAL
August 1, 2011
Roy Humphrey
1455 Begonia Street
Atlantic Beach, FL 32233
861-5878
We will provide labor, material and permit to run approximately 66' of 4" Schedule 40 sewer line and
tap into 6" city lateral. Backhoe service will be used to facilitate the job. Ditches will be backfilled to
grade. We will contact Central Locating to mark utilities. Please allow 3 to 5 days for locating
contract is signed. g once
We will permit through the Duval County Health Department to abandon the septic tank; it will be
Pumped out and then inspected by Health Department officials and filled with clean fill after the
inspection.
DWV to be Schedule 40 PVC. Water piping to be CPVC. Water taps, sewer taps and any other city
charges to be billed to and paid for by owner/builder. Patchwork and landscaping are not
responsibility of plumber. Price does not include permit fee.
A signed copy of this contract must be in our possession before the mentioned work commences.
Freight charges on special order items to be paid for by owner/builder.
Christy First Coast Plumbing, Inc. will warranty our craftsmanship (installation only of products an
materials) for one year after completion of job. Products and material provided by Christy First Coast
Plumbing, Inc. will carry the manufacturer's own warranty as applicable on defective products. The
term "defective" shall not be construed as embracing damage that arises from misuse, negli ence
Acts of God, normal wear and tear or failure to follow operating or cleaning instructions. g
Warranty work will be performed during regular working hours between 8:00 a.m. and 5:00 .m.
Monday through Friday, except on holidays. P ,
at Nor X
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We propose to furnish material and labor in accordance with the above prices and specifications for
the sum of Two Thousand Six Hundred Forty Five Dollars ($2,645.00). This price is for work
performed during normal business hours; no overtime included.
DRAWS: $2,645.00 to be paid upon job completion.
Draws to be paid when Invoice is presented. If not paid, a service charge of 1.5% of the unpaid
balance per month (18% annum) plus all cost of collection, including attorney's fees incurred in the
event of legal action will be assessed. No plumbing will be performed unless or until prior billings for
this job have been paid.
The above prices, specifications and conditions are satisfactory and are hereby accepted. You have
authorization to perform the work as specified above.
Signature
Date
Our proposal is subject to any industry standard price increases.
Page No. of Pages
BILL FENWICK PLUMBING, INC.
State Certification #CFC019174
8245 Beach Blvd.
JACKSONVILLE, FLORIDA 32216
(904) 724-7022
FAX (904) 724-8869
PR SAL SU ED TO
PHONE
DATE
S.
JOB NAME
CITY.STATE ZIP CODE
6c'
JOB LOCATION
ARCHITECT
DATE OF PLANS
JOB PHONE
We herebysubm' pecifications and estimates for:
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Pe Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
vl�-
dollars ($ 44 9—cc ).
Payment to be made as follows: J` M
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized W
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Our Note: This proposal ay
withdrawn by us if nm arranta with __. rtays_
worxers are curry covereo Dy womman s w pensaua
�CrQtt{zlnCQ of 79ralTQ$a—The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature
0101VIR QR Yf PROPOSAL
Com/ J PO BOX 11303
V JACKSONVILLE, FLORIDA 322341303
z:=--P/LQM- B 1 NG
PHONE (904) 7247211 FAX (904) 7245925
CFCO225M
Date:
9/28/2011
Name:
Roy Humphrey Phone: 861-5878 Fax:
Street:
1455 Begonia Street Job Name: Cell:
CSZ:
Atlantic Beach, Fl. 32233 Job Location:
Atte:
E-mail: oetwiida20aa c«„
wE,E"E9v lleYrt 9PECfC,T[}13 Y!D ESTN.TES FCF
Subject:
Sewer reversal
Procedure:
1) All underground cable locates must be secured prior to digging (Our responsibility).
2) We shall remove the side fence, set aside to be reinstalled at a later date.
Pump out (1) septic tank, in the back yard, break hole in the bottom of tank and fill tank with clean fill dirt.
We are not removing the drain field and/or drain field materials.
A backhoe will be used backfill the tank.
3) Reroute (1) sewer line at the rear of house to the stake in the front yard to the city tap, approximately 62 foot.
`Location of the city tap will need to be located prior to the start of the job. Owner's responsibility.
All drain materials will consist of 4" sch 40 PVCDWV pipe and fittings.
Install (1) cleanout at the rear of the home to grade as required and 1-at the city tap.
4) Install a 3/4" sch 40 pvc pipe and fittings water service from the city provided water meter to the
front of the house and tie into the existing 3/4" galv water line.
Install 1-3/4" brass ball valve above grade to isolate the house water.
5) The electrical regrounding of the home shall be handled thru us as requried by the plumbing code.
6) All ditches shall be dug and backfilled using a small backhoe.
Note:
No sod replacement is included in this bid.
7) Have all work permitted and inspected by health dept. and local plumbing officials.
1 year warranty parts and labor.
No warranty on existing plumbing systems or connections to them. No warranty against stoppages.
8) All city tap fees, downstream pollution fees, water meter fees, water capacity fees shall be the
the responsibility of the homeowner.
Price is based on information given by owner and JEA specifications. Any additional outlets at house,
concrete removal and/or replacement, additional septic tanks, and piping footage above specified amount
will be at an additional charge.
9) Total Contract
Pump out expense, health dept permit, abandonment $ 1,098.00
Plumbing permit $ 100.00
Plumbing materials $ 500.00
Plumbing labor $ 1,760.00
Electrical regrounding of home $ 200.00
$ 3,658.00
Thank
II!
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PAYMENTS TO aE MADE AS FOLLOWS: due upon completion
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SIGNATURE
SIGNATURE
Property Appraiser - Property Details
HUMPHREY ROY E
1455 BEGONIA ST
ATLANTIC BEACH, FL 32233-1846
1455 BEGONIA ST
Prnnerty Detail
Primary Site Address
1455 BEGONIA ST
Atlantic Beach FL 32233
RE #
171082-0000
Tax District
USD3
Property Use
0100 SINGLE FAMILY
# of Buildings
1
Legal Desc.
18-34 38 -2S -29E
ATLANTIC BEACH SEC H
Subdivision
03119 ATLANTIC BEACH SEC H
The sale of this property may result in higher property taxes. For more information go
to Save Our Homes and our Property Tax Estimator . Property values, exemptions and
other information listed as 'In Progress' are subject to change. These numbers are
part of the 2011 working tax roll and will not be certified until October. Learn how the
Property Appraiser's Office values property.
Page 1 of 1
Official Record Book/Page Tile #
08754-00966 9418
Value SIJITInlary
Value Method
CAMA
CAMA
Total Building Value
$75,392.00
$58,058.00
Extra Feature Value
$1,276.00
$2,464.00
Land Value (Market)
$33,375.00
$33,375.00
Land Value (Aeric.)
$0.00
$0.00
Just (Market) Value
$110,043.00
$93,897.00
Assessed Value
$67,353.00
$68,363.00
Cap Diff/Portability Amt
$42,690.00 / $0.00
$25,534.00 / $0.00
Exemptions
$42,353.00
See below
Taxable Value
$25,000.00
See below
Taxable Values and Exemptions — In Progress
If there are no exemptions applicable to a taxing authority, the Taxable Value is the same as the Assessed Value listed above in the Value Summary box.
County/Municipal Taxable Value SJRWMD/FIND Taxable Value School Taxable Value
Assessed Value $68,363.00 Assessed Value $68,363.00 Assessed Value $68,363.00
................................................................................................................................................................................................................................................................................................................................
Homestead Exemption (HX) - $25,000.00 Homestead Exemption (HX) - $25,000.00 Homestead Exemption (HX) - $25,000.00
Amend 1_..
Homestead......(HB) - $18,363.00 Amend 1 Homestead (HB) $18,363.00 Taxable Value $43,363.00
...................
Taxable Value $25,000.00 Taxable Value $25,000.00
SaIPC Hictnry
Book/Page
Sale Date
Sale Price
Deed Instrument Type Code
Oualified/Unqualified
Vacant/Improved
08754-00966
( 10/16/1997
$100.00
MS - Miscellaneous
Unqualified
Improved
08762-02417
10/14/1997
$100.00
QC - Quit Claim
Unqualified
Improved
07028-02308
1/11/1991
$57,000.00
WD - Warranty Deed
Qualified
Improved
06363-01580
4/29/1987
$53,790.00
WD - Warranty Deed
Unqualified
Vacant
06070-01101
1/3/1986
$21,000.00
WD - Warranty Deed
Unqualified
Vacant
Fvtra Faaturac
LN
Feature Code
Feature Description
Bldg.
Length
Width
Total Units
Value
1
FPPR7
Fireplace Prefab
1
00
1.00
$1,017.00
2
SFRR2
Sun Room Fla Room
1
15
19
135.00
$1,447.00
Land & Legal
Land
LN Code � Use Description ;Zoning Front Depth Category Land Units Land Value
11 0100 RES LD 3-7 UNITS PER AC ARS -2 50.00 102.00 I Common 150.00 $33,375.00
More Information
arcel Tax Record I GIS Mao I Mao this property on Google Maps I City Fees Record
Legal
LN
Legal Description
1
18-34 38-25-29E
2
ATLANTIC BEACH SEC H
3
LOTS 4 BLK 251
http://apps.coj.net/pao_propertySearch/Basic/Detail.aspx?RE= I ... 10/11/2011
S, CITY OF ATLANTIC BEACH
PUBLIC UTILITIES
—� 1200 Sandpiper Lane
ATLANTIC BEACH, FL 32233
(904) 270-2535 or (904) 247-5874
NEW WATER/SEWER TAP REQUEST 41
Date: 10/11/2011 Project Address: 1455 Begonia Street
No. of Units: 1 Commercial Residential XXX Multi -Family
New Water Tap(.$), & Meter(s), Meter Size(s).
New Irrigation Meter Upgrade Existing Meter from to (size)
New Connection to City Sewer XXX
Name: Roy E. Humphrey
Applicant Address: 1455 Begonia Street
City: Atlantic Beach State: FL Zip: 32233
Phone Number: 904 861-5878 Cell Number: Same
Email Address Fax:
ilu
Signature: _ Submitted by David E. Thompson
(Applicant) _-
CITY STAFF USE ONLY
Application#
Water System Development Charge $ 0
Sewer System Development Charge $ I/ Off _
Water Meter Only $___�__
Water Meter Tap $
Sewer Tap $
Cross Connection $D
Other - Ch rba l A-rVA VA $2
TOTAL $ f 070 f_
C�nnccisi1 {' G
(notes)
APPROVED: /%,, , _ _, Y_ /C_
(UliliN Dire or or A ulk0ized Signature)
ALL TAP REQUEST MUST BE APPROVED BY UTLITIES DEPARTMENT BEFORE FEES
CAN BE ASSF,SSED
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(ITY OF ATLANTIC BEACH
800 SEMINOI.E ROAD
' ATLANTIC BEACH. FLORIDA 32233-4445
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH FL 32233
PEOWER 908 U.8 MTENT Ib. 5518390, 55:5589 SBnf �.8�. s'--: • .
CITY OF ATLANTIC BEACH
R00SEMINOLE ROAD NO. 102503
u -Home i»�a�aat
INVOICE
NI(M8E[i
INVOICE
DATE,
PURCHASE' -
ORDER NO.
PP401ECT
\`UMBER
N�N9�it
AMOLNT
RE# 171082-0000
10/20/2011
110-5506-535.83-00
5,425.00
GROSS
RF,TAINAGE
DISCOUNT
NET
$******5,425.00
$******5,425.00
City of Atlantic Beactf
tff WiflWY 0-'klPr "t
Over: WMFY lype: IC Pra»er: 1
Date: 16/26/11 @6 geoeiot no. :Yw
Description Quantity ruouut
poll
BP HU1LDI* Ptfd1115
Tender detail
fotal tendered to
Total payment $Wj.N
Trans date: 18MAI file: Ii:Bl:tS
CITY OF ATLANTIC BEACH
PUBLIC UTILITIES
1200 Sandpiper Lane
ATLANTIC BEACH, FL 32233
(904) 270-2535 or (904) 247-5874
NEW WATER/SEWER TAP REQUEST
Date: 10/11/2011 Project Address: 1455 Begonia Street
No. of Units: 1 Commercial Residential XXX Multi -Family
New Water Tap(s) & Meter(s)
New Irrigation Meter
Meter Size(s)
Upgrade Existing Meter from to__ (size)
New Connection to City Sewer XXX
Name: Roy E. Humphrey
Applicant Address: 1455 Begonia Street
City: Atlantic Beach State: FL Zip: 32233
Phone Number: 904 861-5878 Cell Number: Same
Email Address Fax:
Signature: Submitted by David E. Thompson
(Applicant)
CITY STAFF USE ONLY
Application#
Water System Development Charge $
Sewer System Development Charge $ D
Water Meter Only $SBS
Water Meter Tap $ _
Sewer Tap $
Cross Connection
Other - Chr)SA, GrsFC�ns� $ 2
TOTAL
$x;070
Coyi ✓•e�slor, i/J �/c�des
(notes)
APPROVED:
(Utility Dire or or Aut ized Signature)
ALL TAP REQUEST MUST BE APPROVED BY UTLIT IES DEPARTMENT BEFORE FEES
CAN BE ASSESSED
1�Q9G(itj>L!'Jn 0s34,7- ("k ..P Z,�yJ
PREPARED 10/20/11, 10:51:04 PAYMENTS DUE RECEIPT
CITY OF ATLANTIC BEACH PROGRAM BP820L
---------------------------------------------------------------------------
APPLICATION NUMBER: 11-00000504 1455 BEGONIA ST
FEE DESCRIPTION AMOUNT DUE
---------------------------------------------------------------------------
SEWER SDC -SYSTEM DEV CHG 4050.00
WATER CONNECT/METER ONLY 185.00
WATER CROSS CONNECTION 50.00
WATER SDC -SYSTEM DEV CHG 1140.00
TOTAL DUE 5425.00
Please present this receipt to the cashier with full payment.