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478 9th Street West WELL-SEPTIC CONVERSION App 05.13.2011 , . , . ‘. • O � sr „..„ �qY 4.8, ,,,, :; s~ By 17 , 1 City 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: `j t 1. Homeowner Name(s): iViecce. ..,e2, 7k, cn r ILAAAAeir 2. Address of Home: 141-1`R W, 1 T y- ; c� _ rn �_ c.:.. .._ti 11 �'� 1( 3. Telephone Number: CP) I - 3149- /4 O3 B (day) 92 —?, Le:::(— S'I9'1 (night 4. Is the person completing this application the Head of Household? yes ❑ no ❑ female ❑ male 5. How many family members live in this house? 1 6. Are there people living in this house with disabilities or special needs? ❑ yes no If yes, please explain 7. Number and age of persons living in the household in addition to Head of Household. Ages 0—5 years old Male Female Ages 6— 17 years old Male Female Ages 18—39 years old Male ( Female Ages 40—64 years old Male Female Ages 65 and older Male Female 8. Water supply is provided by: Mtlry Water ❑ Private Well Other 9. Does septic system work properly? Yes ❑ No If no,please explain. Page 1 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? Yes ❑ No 12. Do you have a complete kitchen with running water,a refrigerator and cooking facilities? \I E' 13. How many persons are in your family and living at this address? I 14. Federal regulations require that we keep track of certain demographic information and the type of households being served. PI se 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 �{ tt 15. What is the total annual income(before taxes)of your household? i4i ,119 19 Ca D (0 ftdj 55 16. Are you on a fixed income such as Social Security, SSI or retirement? ❑ Yes RIO - 17. What are your sources of inc me? \AD d r CM i c I Z�4f' --VA " 'c- --4A=E 18. Do you own this home? R Yes ❑ No like--&--1- `-}c:: •-/Y'S.> If you own your home, please provide a copy of your deed and a recent water or electric bill which shows that you live at this address. If yo rent your home,please provide a copy of the lease. '1\V/A j ( 31( ( Signature of Owner 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. — ii 3 -- i ZS -• Page 2 of 3 INCOME VERIFICATION FORM PART I. (To be filled out by the person (employee) completing this application.) Applicant :\A / Employee name: PJf'C A .16 r�-Vl ne,(in l/ ` rC't \ Address: `�j �S Wp ���� Astk: Social Security Number: 1 — 3 9 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 Program, which is funded by a Community Development Block Grant. Signature of Owner Date 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: \kk 11C1f t‘f N Gross Monthly Income: $ OC) I Oci1_/©) Is employment: IX permanent part-time temporary Employer Name: 5,0 r Address: v.Z`( 3 i Telephone: 94 (O oohed/ 51(17114/v (a Fo O Name and title of person providing this information. Date Page 3 of 3 THIS INSTRUMENT PREPARED BY: • William G. Noe,Jr., Esquire • 599 Atlantic Blvd., Suite 6 Atlantic Beach, FL 32233 (904)249-7241 09-3386 i$ jai COO.Do GENERAL WARRANTY DEED THIS DEED, made as of the 9th. day of November, 2009, between LORRAINE SAVAGE GUENTHER and LEO E. GUENTHER, her husband, "Grantor", whose mailing address is 759 Porta Rosa Circle, St. Augustine, Florida 32092, party of the first part, and MERCEDES A. BRUNNER and DONALD J. DAGLEY, as joint tenants with right of survivorship and not as tenants in common, "Grantee", whose mailing address is 478 W. 9th. Street, Atlantic Beach, Florida 32233, party of the second part, WITNESSETH: The Grantor, for and in consideration of Love and Affection and One Dollar and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, has granted, bargained, and sold to Grantee, Grantee's heirs, successors and assigns, forever, that certain parcel of land located in the County of Duval and State of Florida, more particularly described as: Lot 1, Block 149, SECTION "H", ATLANTIC BEACH, according to plat thereof recorded in Plat Book 18, Page 34, of the current public records of Duval County, Florida. RE# 170935-0000 SUBJECT to covenants, conditions, restrictions, easements and encumbrances of record, this reference to which shall not operate to reimpose the same. TO HAVE AND TO HOLD the same in fee simple, subject to taxes and assessments for the year of conveyance. TOGETHER WITH all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. Grantor hereby covenants with said Grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title of said land; that the grantor will defend the same against the lawful claims of all persons whomsoever. IN WITNESS WHEREOF, the said Grantor has signed and sealed these presents the day and year first above written. Signed, sealed and delivered in the presence(.f m://z. 1 i ..;4LORRAINE SAVAGE GUENT ess: WILLIA G. NOE, JR. Witness: DEBRA A. RENTZELL 0 E. GUENT ER vili STATE OF FLORIDA COUNTY OF DUVAL • The foregoing instrument was acknowledged before me this 9th. day of November, 2009, by LORRAINE SAVAGE GUENTHER and LEO E. GUENTHER, her husband, who are personally known to me, or who produced Driver's License as identification, and did not take an oath. f,, Duval County, Florida. • RE# 170935-0000 • SUBJECT to covenants, conditions, restrictions, easements and encumbrances of record, this reference to which shall not operate to reimpose the same. TO HAVE AND TO HOLD the same in fee simple, subject to taxes and assessments for the year of conveyance. TOGETHER WITH all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. • Grantor hereby covenants with said Grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title of said land; that the grantor will defend the same against the lawful claims of all persons whomsoever. IN WITNESS WHEREOF, the said Grantor has signed and sealed these presents the day and year first above written. Signed, sealed and delivered in the presence - L LORRAINE SAVAGE GUEN i r i2 • ess: WILLIA G. NOE, JR. 0"91,0174110. • Witness: DEBRA A. RENTZELL O E. GUEN ER STATE OF FLORIDA COUNTY OF DUVAL The foregoing instrument was acknowledged before me this 9th. day of November, 2009, by LORRAINE SAVAGE GUENTHER and LEO E. GUENTHER, her husband, who are personally known to me, or who produced Driver's License as identification, and did not take an oath. %IL NOTARY PUBLIC Doc##2009270384,OR BK 15062 Page 485, Number Pages: 1 Recorded 11/09/2009 at 11:33 AM WILLIAM G.NOE JR. ��n ti''•. JIM FULLER CLERK CIRCUIT COURT DUVAL 7 ,.� '__ Commission DD 820315 RECORDINGCOUNTY y�; �:;• Expires September 7,2012 DEED DOC ST $1001:00 $10.00 • :frP Bonded Thra Troy Fain Insurance 800-38.4/019 591 23: City of Atlantic Beach 300 Seminole Road Account Number: 58577-2037 Customer Name: MERCEDES A. BRUNNEI 4tlantic Beach, FL 32233 Service Address: 478 W 9TH S' telephone: (904) 247-5816 Bill Date: 05/14/1 :ax: (904) 247-5877 Current Charges Due Date: 05/31/1 Service Period Meter Number Current Reading Previous Reading Usage in 1000 Gallons 14/07/11 TO 05/06/11 68698355 46.00 43.00 3.00 Service Total Service Total VATER VOLUME GARBAGE RANGE 1 TO 3,000 3.06 GARBAGE SERVICE 17.7E VATER BASE STORM WATER UTILITY WATER BASE 8.97 STORMWATER 5.00 CURRENT BILL 34.8' PREY.BALANCE 0.0( TOTAL DUE 34.81 AFTER DUE DATE PAY 38.29 MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY PERIOD GAL X 1000 DAILY AVG. CURRENT 3 0.103 LAST PERIOD 1 0.033 YEAR AGO 2 0.068 PLEASE BRING ENTIRE BILL IF PAYING IN PERSON. PLEASE DETACH AND RETURN BOTTOM PORTION IF PAYING BY MAIL. FL22574I ACCOUNT# BILLING DATE 05/14/1 City of Atlantic Beach 58577-20376 CURRENT BILL 34.8' 800 Seminole Road Atlantic Beach,FL 32233-5444 DUE DATE PREY. BALANCE 0.0( 05/31/11 34.81 Address Service Requested AFTER DUE DATE PAY 38.29 Check Box For Change of Address or Bank Draft Sign Up PLEASE ENTER AMOUNT PAID $ *AUTO ***AUTO**5-DIGIT 32233 I'IIII'IIIIII"'IIIIIIIIIIIIIIII"IIIIIIIIII'IIIIIIIII,IIIIII"" City of Atlantic Beach 03-21 MERCEDES A.BRUNNER 800 Seminole Road 478 W 9TH ST Atlantic Beach, FL 32233-5444 ATLANTIC BEACH FL 32233-2550 595 3 IIIIIIIIII,II1IIIIIII'IIIIIII'I'IIIIIII"II'IIIII'III'III'IIIIIII Property Appraiser - Property Details Page 2 of 2 Total 11628 11284 I (Element Code Stories 2.000 Bedrooms 2.000 Baths 1.000 Rooms/Units 1.000 http://apps.coj.net/pao_propertySearch/Basic/Detail.aspx?RE=170... 9/9/2011 Property Appraiser - Property Details Page 1 of 2 BRUNNER MERCEDES A ET AL Primary Site Address Official Record Book/Page Tile# 478 9TH ST W 478 W 9TH ST 15062-00485 9418 ATLANTIC BEACH, FL 32233-2550 Atlantic Beach FL 32233 DAGLEY DONALD J R/S 478 W 9TH ST Property Detail Value Summary RE# 170935-0000 2010 Certified 2011 In Proess , Tax District USD3 Value Method CAMA CAMA ..._ gr Property Use 0100 SINGLE FAMILY Total Building Value $86,113.00 $67,531.00 #of Buildings 1 Extra Feature Value $2,910.00 $2,396.00 18-34 38-2S-29E Land Value(Market) $46,725.00 $46,725.00 Legal Desc. SEC H ATLANTIC BEACH Land Value(Aoric.l $0.00 $0.00 Subdivision 03119 ATLANTIC BEACH SEC H Just(Market)Value $135,748.00 $116,652.00 The sale of this property may result in higher property taxes.For more information go Assessed Value $135,748.00 $116,652.00 to Save Our Homes and our Property Tax Estimator.Property values,exemptions and Cap Diff/Portability Amt $0.00/$0.00 $0.00/$0.00 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 Exemptions $50,000.00 See below Property Appraiser's Office values property. Taxable Value $85,748.00 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 $116,652.00 Assessed Value $116,652.00 Assessed Value $116,652.00 Homestead Exemption(HX) -$25,000.00 Homestead Exemption(HX) -$25,000.00 Homestead Exemption(HX) -$25,000.00 Amend 1 Homestead(HB) -$25,000.00 Amend 1 Homestead(HB) -$25,000.00 Taxable Value $91,652.00 Taxable Value $66,652.00 Taxable Value $66,652.00 Sales History Book/Page I Sale Date Sale Price Deed Instrument Type Code I Oualified/Unaualified I Vacant/Improved 15062-00485 11/9/2009 $143,000.00 WD-Warranty Deed Qualified I Improved 13651-00556 10/6/2006 $30,000.00 QC-Quit Claim Unqualified Improved 09192-02589 12/30/1998 $66,900.00 WD-Warranty Deed Unqualified Improved 09126-00525 11/4/1998 $100.00 SW-Special Warranty Unqualified Improved 09079-00576 9/22/1998 $100.00 CT-Certificate of Title Unqualified Improved 07115-01171 5/17/1991 $69,900.00 WD-Warranty Deed Qualified Improved 05753-02232 1/31/1984 $5,500.00 WD-Warranty Deed Unqualified Improved Land&Legal Land _ Le•al LN Code I Use Description zoning I Front Depth Category I Land Units I Land Value LN Legal Description 1 0100 I RES LD 3-7 UNITS PER AC ARG-1A 170.00 102.00 I Common 170.00 I$46,725.00 1 18-34 38-2S-29E 2 SEC H ATLANTIC BEACH 3 LOT 1 BLK 149 Buildings Building 1 Building 1 Site Address Element Code Detail 478 W 9TH ST Atlantic Beach FL 32233 Exterior Wall 6 6 Vert Sheet Siding Roofing Structure 3 3 Gable or Hip Building Type 0103-SFR SPLIT-LEVEL SOH Roofing Cover 3 3 Asph/Comp Shingle riBAs ;-"i Year Built 1986 Interior Wall 5 5 Drywall ii,T-__I _F,,. L " Int Flooring 11 11Ceramic Clay Tile FGR lugGross Area Heated Area Int Flooring 14 14 Carpet �` I Finished upper story 1 504 504 ( Heating Fuel 4 4 Electric Base Area 780 780 Heating Type 4 4 Forced-Ducted Finished Garage 288 0 Air Conditioning 3 3 Central Finished Open Porch 56 I 0 http://apps.coj.net/pao propertySearch/Basic/Detail.aspx?RE=170... 9/9/2011 J' f J� tifp CITY OF ATLANTIC BEACH ss1 800 SEMINOLE ROAD s ATLANTIC BEACH, FLORIDA 32233-5445 Ti' TELEPHONE: (904) 247-5800 FAX: (904) 247-5805 J131>Pi ? www.coab.us June 27, 2011 Mercedes A. Brunner 478 W. 9th Street Atlantic Beach,FL 32233 Dear Ms.Brunner; The purpose of this letter is to confirm that the City of Atlantic Beach has received your APPLICATION FOR ASSISTANCE WITH CONVERSION FROM WELL AND SEPTIC TANK TO CITY WATER AND SEWER. At the present time,the City is compiling the applications and information so that we can schedule these projects in the coming year. The funding should be available starting in October 2011. City staff will contact you to review your application to assure that you qualify for the financial assistance. Additionally, staff will provide you with direction and guidance so that you can obtain qualified help to perform the services. This will be explained to you in more detail within the next few months. In the meantime, if you any have questions,then you are welcome to contact me for further discussion. Thank you for expressing your interest in this program. Sincerely yours, David E. Thompson Asst. City Manager 1040 Department of the Treasury—Internal Revenue Service ��10 U.S. Individual Income Tax Return (99) IRS Use Only—Do not write orstaple inthis space. P For the year Jan.1–Dec.31,2010,or other tax year beginning ,ending OMB No.1545-0074 Name, R Your first name M.I. Last name Suffix Your social security number Address, N MERCEDES A. BRUNNER -1339 and SSN T If a joint return,spouse's first name M.I. Last name Suffix Spouse's social security number C L Home address(number and street).Ifyou have a P.O.box,see instructions. Apt.no. See separate E ) p A Make sure the SSN(s)above instructions. R 478 W. 9TH STREET and on line 6c are correct. L City,town or post office,state,and ZIP code.If you have a foreign address,see instructions. Checking a box below will not Presidential Y 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 ► n You n Spouse Ellin Status 1 U Single 4 n Head of household(with qualifying person).(See instructions.)If g 2 Married filingjointly(even if onlyone had income) the qualifying person is a child but not your dependent,enter this child's name here. 3 n Married filing separately. Enter spouse's SSN above and full name here. P. Check only one I. First name Last name SSN box. First name Last name 5 Qualifying widow(er)with dependent child � Boxes checked Exemptions 6a 1^1 Yourself. If someone can claim you as a dependent,do not check box 6a } on 6a and 6b 1 b El Spouse No.of children c Dependents: (4)Jif child under age 17 on 6c who: p (2)Dependent's (3)Dependent's •lived with you 0 qualifying for child tax credit •did not live with social security number relationship to you (see page 15) (1)First name Last name you due to divorce If more than four ❑ or separation 0 dependents,see ❑ (see instructions) instructions and El Dependents on 6c noten entered above 0 check here ► 0 Add numbers on d Total number of exemptions claimed lines above P. Income 7 Wages,salaries,tips,etc. Attach Form(s)W-2 7 10,699 8a Taxable interest. Attach Schedule B if required 8a 96, Attach Form(s) b Tax-exempt interest. Do not include on line 8a I 8b I I W-2 here.Also 9a Ordinary dividends. Attach Schedule B if required 9a attach Forms b Qualified dividends I 9b I I W-2G and 10 Taxable refunds, credits,or offsets of state and local income taxes 10 1099-R if tax was withheld. 11 Alimony received 11 12 Business income or(loss). Attach Schedule C or C-EZ 12 13 Capital gain or(loss). Attach Schedule D if required. If not required,check here ►❑ 13 If you did not 14 Other gains or(losses).Attach Form 4797 14 get a W-2, 15a IRA distributions 15a i I I b Taxable amount 15b see page 20. l 16a Pensions and annuities 16a b Taxable amount 16b Enclose,but do 17 Rental real estate, royalties, partnerships, S corporations,trusts,etc. Attach Schedule E . . . 17 not attach, any 18 Farm income or(loss). Attach Schedule F 18 payment.Also, 19 Unemployment compensation 19 please use 20a Social security benefits . . . . . . 120a I I I b Taxable amount 20b 0 Form 1040-V. 21 Other income. List type and amount State Tuition- 1099-Q 21 1,124 22 Combine the amounts in the far right column for lines 7 through 21.This is your total income. . I. 22 11,919 Adjusted 23 Educator expenses 23 24 Certain business expenses of reservists,performing artists,and Gross fee-basis government officials.Attach Form 2106 or 2106-EZ. . . . 24 Income 25 Health savings account deduction.Attach Form 8889 25 26 Moving expenses. Attach Form 3903 26 27 One-half of self-employment tax. Attach Schedule SE 27 28 Self-employed SEP,SIMPLE,and qualified plans . . . 28 29 Self-employed health insurance deduction 29 30 Penalty on early withdrawal of savings 30 31a Alimony paid b Recipient's SSN ► 31a 32 IRA deduction . . . 32 33 Student loan interest deduction 33 34 Tuition and fees.Attach Form 8917 34 35 Domestic production activities deduction.Attach Form 8903 35 36 Add lines 23 through 31a and 32 through 35 36 37 Subtract line 36 from line 22. This is your adjusted gross income ► 37 11,919 =or Disclosure,Privacy Act,and Paperwork Reduction Act Notice,see separate instructions. Form 1040 (2010 HTA) • r • r .-orm 1040(2016) MERCEDES A. BRUNNER IIM1339 Page 2 38 Amount from line 37(adjusted gross income) 38 11,919 Talc and 39a Check ,1n You were born before January2, 1946, Blind. Credits f _ i Total boxes checked ► if: Spouse was born before January 2,1946, Blind. 39a b If your spouse itemizes on a separate return or you were a dual-status alien,check here. ► 39b 40 Itemized deductions(from Schedule A)or your standard deduction(see instructions) 40 5,700 41 Subtract line 40 from line 38 41 6,219 42 Exemptions.Multiply$3,650 by the number on line 6d 42 3,650 43 Taxable income.Subtract line 42 from line 41. If line 42 is more than line 41,enter-0- . 43 2,569 44 Tax(see instructions).Check if any tax is from: a Form(s)8814 b❑Form 4972. . . 44 256 45 Alternative minimum tax(see instructions). Attach Form 6251 45 46 Add lines 44 and 45 ► 46 256 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 49 256 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 n 3800 b FI 8801 c Fl 53 54 Add lines 47 through 53.These are your total credits 54 256 55 Subtract line 54 from line 46. If line 54 is more than line 46,enter-0- ► 55 0 Other 56 Self-employment tax.Attach Schedule SE 56 57 Unreported social security and Medicare tax from Form: a n 4137 b 1 18919 57 Taxes 58 Additional tax on IRAs,other qualified retirement plans,etc.Attach Form 5329 if required 58 59 a Form(s)W-2, box 9 b I I Schedule H c Form 5405, line 16 59 60 Add lines 55 through 59.This is your total tax. . . . . . .► 60 0 Payments 61 Federal income tax withheld from Forms W-2 and 1099 61 424 62 2010 estimated tax payments and amount applied from 2009 return . . . 62 63 Making work pay credit.Attach Schedule M 63 400 If you have a 64a Earned income credit(EIC) 64a qualifying b Nontaxable combat pay election 164b I I child,attach 65 Additional child tax credit.Attach Form 8812 65 Schedule EIC. - 66 American opportunity credit from Form 8863,line 14 66 360 67 First-time homebuyer credit from Form 5405, line 10 67 68 Amount paid with request for extension to file 68 69 Excess social security and tier 1 RRTA tax withheld 69 70 Credit for federal tax on fuels.Attach Form 4136 70 71 Credits from Form: a 2439 b Ii 8839 c ri 8801 d 8885 71 72 Add lines 61,62,63,64a,and 65 through 71.These are your total payments. . ► 72 1,184 Refund 73 If line 72 is more than line 60,subtract line 60 from line 72.This is the amount you overpaid. 73 1,184 74a Amount of line 73 you want refunded to you. If Form 8888 is attached,check here I.U 74a 1,184 ► b Routing number 256074974 ► c Type: EI ^Checking I I Savings Direct deposit? See ► d Account number 0818261406 instructions. 75 Amount of line 73 you want applied to your 2011 estimated tax . . . ► I 75 I 1 Amount 76 Amount you owe.Subtract line 72 from line 60. For details on how to pay,see instructions ► 76 0 You Owe 77 Estimated tax penalty(see instructions) I 77 I I Third Party Do you want to allow another person to discuss this return with the IRS(see instructions)? ri Yes.Complete below. I I No Designee's Phone Personal identification Designee name I. Preparer n0 ► (904)242-4829 number(PIN) Ili'170 1 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 Here belief,they are true,correct,and complete.Declaration of preparer(other than taxpayer)is based on all information of which preparer has any knowledge. Joint return? Your signature Date Your occupation Daytime phone number See page 12. STUDENT (904) 349-4050 Keep a copy for your Spouse's signature.If a joint return,both must sign. Date Spouse's occupation records. i Print/Type preparer's name Preparer's signature Date Check Ii if PTIN Paid Michael Mette Michael Mette 2/18/2011 self-employed P00401362 Preparer Firm's name ►Your Tax Place, Inc. Firm's EIN ► 26-2915889 Use Only Firm's address 10'1639 Beach Blvd Jacksonville BeactFL 32250 Phone no. (904)242-4829 Form 1040 (2010 at ' tOCITY OF ATLANTIC BEACH ssl 800 SEMINOLE ROAD s) ATLANTIC BEACH, FLORIDA 32233-5445 TELEPHONE: (904) 247-5800 FAX: (904)247-5805 JI www.coab.us October 12,2011 Ms. Mercedes A. Brunner 478 West 9th Street Atlantic Beach, FL 32233 Dear Ms. Brunner, We received your application for grant funding to pay for connecting your existing septic tank system to the City's sewer system. Our preliminary review of your application indicates that you will qualify for grant funding to pay for these expenses. We have been unable to contact you through the telephone numbers on your application, and we need to talk with you to move forward on the project. Please contact me at your earliest convenience and provide me with a telephone number,email address, or other means of communications. I may be reached at: (904)247-5864 Office (904)403-4318 Cell City Hall 800 Seminole Road Atlantic Beach, FL 32233 Sincerely yours, David E. Thompson Asst. City Manager -- - H �_ s__!j 41glitis A . /Jii Vii' NEW WATER/SEWER TAP REQUEST Date: 10/28/11 Project Address: 478 W. 9th St. No. of Units: 1 Commercial Residential x Multi-Family New Water Tap(s) & Meter(s) Meter Size(s) New Irrigation Meter Upgrade Existing Meter from to (size) New Connection to City Sewer 1 Name: Mercedes A. Brunner Applicant Address: 478 W. 9th St. City: Atlantic Beach State: FL Zip: 32233 Phone Number: (904) 349-5197 (Diane Dagley) Cell Number: Email Address Fax: Signature: (Applicant) CITY STAFF USE ONLY Application# Sewer SDC fee to connect to City sewer, Water System Development Charge $ and cost of plumber for CDBG grant. Sewer System Development Charge $ 4,050.00 Water Meter Only $ Water Meter Tap S Sewer Tap $ Cross Connection $ Other (Advantage Plumbing) $ 1,970.00 TOTAL $ 6,020.00 • APPROVED: - IO-2r- // (Utility Director or Author-:}d Signature) ALL TAP REQUEST MUST BE APPROVED BY UTLITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED October 25,2011 Mr David Thompson Asst City Mgr City of Atlantic Beach Mr. Thompson, Per our phone conversation of October 19, attached you will find the paperwork requested. The paperwork is in reference to the septic system grant application for Mercedes A Brunner at 478 West 9th Street. Enclosed is a copy of last year's tax return and 3 bids from local plumbing companies. As we discussed, Mercedes is a full time student and employed part-time. She is mostly unable to answer her phone until late evening. If I can be of any assistance as her mother, I am always available by phone and can usually get a message to her if need be. My name and number is on her application. Thank you again for your assistance in this matter. -re , Diane Dagley : -349-5 ' ./ PrOPOSal Page No. of Pages \ STEEG PLUMBING CO., INC. P.O. Box 330536 ATLANTIC BEACH, FLORIDA 32233-0536 Phone 249-5191 PROPOSAL SUBMITTED TO // /,"14 ,20 PHONE DATE l STREET JOB NAME L/7/ JJe-3 t" 9 . . 5I- CITY,STATE and ZIP CODE JOB LOCATION 141/ /5'2 f/ Y1 .-95 ARCHITECT DATE OF PLANS JOB PHONE ,g t,/G 44407 ,,A.• SY-I'''.5i 3-7 We hereby submit specifications and estimates for: 114 /4111e- 74f) ,,i404170/ di 907.2;.. 1-0/4 4 e e/17)e*.4"4 Y.d .. Z1/7: . ecce ji et elis f .._a)i-o% 0/1 ,B?€ k Lif / `d4/ 1Uzla,/ /,DG 7111 .SiReG72.- /Mit/c., 144 /10NL2 /Atm/ r Pici/ke 6 fes/ f/ Ap". ide ,ti # 'H p tiropo a herebyto furnish material and labor 4,-,TX:r complete in accordance_ with above specifications, for the sum of: 71.'071/d� 2/.4) 140 �� '7 dollars($ ,2 7 S.60 ). Payment to be made as followe 1 /2'. it'e wean e �.9h,f,f All material is guaranteed to be as specified. All work tote completed in a workkanlike Authorized manner according to standard practices.Any alteration or deviation from above specifications Signature involving extra costs will be executed only upon written orders,and will become an extra g ::,.---- charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:T roposal may be \Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us of accepted within days/ Acceptance of Proposal —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 ,J ADVANTAGE P.O.Box 49225 Estimate PLUMBING Jacksonville Beach,FL 32240 Date 10/20/2011 10202011 MB Name/Address Job Address Mercedes Brunner 478 West 9th Street Atlantic Beach,Fl 32082 Item Description Total Sewer/Water Install new sewer from house to new city tap at street with PVC 1,970.00 schedule 40 Pull lids on septic tank and pump out tank Punch holes in bottom of tank fill with dirt and compact for abandonment Sewer and permit$995 Abandonment and permit$975 **This price does not include any city fees Thank you for your interest in Advantage Plumbing.This estimate is good for 30 days. Total $1,970.00 PROPOSAL CHRISTY FIRST COAST PLUMBING, INC. 1651 MAYPORT ROAD, ATLANTIC BEACH, FL 32233 247-4419 (Office); 249-4660 (Fax) CFC 1428444 PROPOSAL October 21, 2011 Mercedes Brunner 478 West 9th Street Atlantic Beach, FL 32233 349-5197 (Diane) drdagley@gmail We will provide labor, material and permit to run approximately 43' 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 once contract is signed. 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. 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 and 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, negligence, Acts of God, normal wear and tear or failure to follow operating or cleaning instructions. Warranty work will be performed during regular working hours between 8:00 a.m. and 5:00 p.m., Monday through Friday, except on holidays. We propose to furnish material and labor in accordance with the above prices and specifications for the sum of Two Thousand One Dollars ($2,001.00). This price is for work performed during normal business hours; no overtime included. DRAWS: $2,001.00 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. Prepared by and return to: David Thompson,Asst. City Manager City of Atlantic Beach 800 Seminole Road Atlantic Beach,FL 32233 - — WELL AND SEPTIC TO WATER—tSEWER- CONNECTION AGREEMENT CITY OF ATLANTIC BEACH, COUNTY OF DUVAL, STATE OF FLORIDA 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: $ 6,020.00 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. Said 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: 478 W 9th Street,Atlantic Beach, FL 32233 Legal Description: SEC H Atlantic Beach, LOT 1 BLK 149 RE# 170935-0000 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 Connection Agreement,the remaining principal balance shall immediately become due to the Holder and collectable without notice, time being of the essence of this Connection 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, Connection Agreement-Page 1 of 2 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. MAKER:- By: AKER:By: \-)1V110) / [/l ,_;_ Date: II ii/ II Mercedes A. Brunner CITY OF ATLANTIC BEACH By: ---____ _. _ _ C-...... / Date: i//s/ii Jim Han/o , City Manager STATE OF FLORIDA COUNTY OF DUVAL Sworn and Subscribed before me this LI Tfl day of IvoVem13e2. , 20 I I , by mee cak A,-gRunflaz who is personally known to me or produced DL# B69,-.9-{I-Ho-'15b 0 A as identification, and who did not take an oath. Gu...jL Notary P lig, State of Florida at Large •-"k, Notary Public stat.of Florida Dayna H Williams �. , i cp My Commission EE119675 ''fo'F.o� Expires 08/07/2015 Connection Agreement-Page 2 of 2