1225 Hibiscus Street WELL-SEPTIC CONVERSION App 02.16.2006 ��
C .L) ( I is .,
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 SEPTIC TANK TO CITY SEWER
2005-2006 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 for single-family residential houses and for homeowners who live in their home.
(Homes cannot be rental houses.) Grant funds are limited, and applicants are selected based upon most
urgent and serious,need and availability of funds.
DATE: �� /5 l
•
1. Homeowner Name(s): k3`-' � (2-3),-Ay S 0 Ze-t/2-1
•
2. Address of Home: 1 `') U(.<9t SC,;J> 5, /T gd\L
•
3. Telephone . ''?-'t' Oa 3 (day) 6 3 (night)
4. Is the person completing this application the Head of Household? Xryes I no n female ❑ male
5. How many family members live in this house? ,3
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: 1:11 ity 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? leYes ❑ No
If no, please explain.
11. Is there hot and cold running water in your house? kr Yes ❑ No
12. Do you have a complete kitchen with running water,a refrigerator and cooking facilities?
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?
16. Are you on a fixed income such as Social Security,SSI or retirement? ❑ Yes 1No
17. What are your sources of income?
18. Do you own this home? 'Yes ❑ No
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 you rent your home, please provide a copy of the lease.
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) 247-5826.
The attached Income Verification Form must also be completed and mailed to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
In order to arrange to inspect your home for needed repairs, 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 Building Inspector to meet with you, and the phone number where you wish
to be called. G`", (- S
Page 2 of 3
INCOME VERIFICATION FORM
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PART I. (To be filled out by the person (employee) completing this application.)
Applicant / Employee name: C\c1/tvx c N�
Address: I /�� D -TR fiT(.4,„v.c,
Social Security Number: -6(i
I hereby authorize release of my income information to the City of Atlantic Beach for
the purpose of applying for participation in the Housing Rehabilitation Assistance
Program, which is funded by a Community Development Block Grant.
G-4//-v4.-6
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Signature ofOwner 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: / e7i).,/
�✓L / ��
Gross Monthly Income: $ /t2
4jnAti ',11.
Is employment: X permanent part-time temporary
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Employer Name: /^J,B ,' 2c4 l ev\ c I- 7
Address: 2-7/ titY P 4/.
Telephone: j
Name and.title of person providin this information. _nat
Department of the Treasury—Internal Revenue Service
Form St
W-2 Waatge andement Tax 200.5 OMB No.
1
545-0008 1 Wages.tips,other compensation 2 Federal income tax withheld
11100 . 00 313 . 02
Copy 2 To Be Filed with Employee's State,City,or Local 7 Social security tips 3 Social security wages 4 Social security tax withheld
Income Tax Return,
11100 . 00 688 . 20
e Employer's name,address.and ZIP code 8 Allocated tips 5 Medicare wages and tips 6 Medicare tax withheld
11100 . 00 160 . 95
South East Emp 1 oye e Leasing 9 Advance EIC payment 10 Dependent care benefits 11 Nonqualitied plans
2739 U.S. Hwy 19 North
Holiday, FL 34691 12a 12b 12c
a Employee's name,address,and ZIP code c12d 73 emp toy �planrement s fp- dy 14 Other
I
RAYMOND MARRERO b Employer identification number(EM) d Employee's social securi number 4
1225 HIBISCUS ST. 59-3744258 154-66- 468
ATLANTIC BEACH, FL 32233
15 State Employer's state I.D.number 16 State wanes,tins.etc. 17 State income tax 18 Local waxes.tins,etc. 19 Local income tax 20 Locality name
Doerr, Sonya •
From: Doerr, Sonya
Sent: Thursday, January 19, 2006 9:41 AM
To: Walker, Chris
Subject: Possible septic to sewer conversion
Chris, when you get a chance can you check and see if sewer is available for this address. Mr. Marrero thinks it is at the
street. He is applying for CDBG funds.
Guess its about time we get started on this; have $90,000 this year for septic to sewer conversions. Thanks!
1225 HIBISCUS ST 171058 0050 Owner: RAYMOND L MARRERO
Sonya
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Page 1 of 1
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http://maps2.coj.net/output/jaxMapsP_GISMAP13168407634382.png 1/19/2006
Duval County Property Appraiser - Parcel Information Page 1 of 1
Owner's Name: MARRERO , RAYMOND L Real Estate Number: 171058 0050
Property Address: 1225 HIBISCUS ST Mailing Address:1225 HIBISCUS ST
City: ATLANTIC BEACH ATLANTIC BEACH , FL
Zip: 32233
Unit Number: Zip:
32233-2609
2006 Exempt Value: $25,000.00
PARCEL DESCRIPTION
Property Use: 0100 SINGLE FAMILY Transaction Date: 4/17/1993
Transaction price
displayed is based on
the actual amount of
Legal Description: 18-34 SEC H ATLANTIC documentary stamps
BEACH LOTS 3,4 BLK 231 - Transaction Price: $53,500.00 paid at the time of
recording. The current
rate is 70 cents per
$100.
Neighborhood: 003119 ATLANTIC BEACH
SEC H
Section/Township/Range: 17-2S-29E No. Buildings: 1
Official Record Book and Page: 07562 Heated Area: 1236
0215
Map Panel: 556A2 Exterior Wall: COMP OR WALL B
VALUES AND TAXES FROM 2005 CERTIFIED TAX ROLL
Land Value: $66,750.00 Taxing Authority: USD3
Class Value: $0.00 County Tax: $199.82
Improvements: $60,480.00 School Tax: $251.49
Market Value: $127,230.00 District Tax: $94.18
Assessed Value: $56,421.00 Other Tax: $15.73
Exempt Value: $25,000.00 Voted Tax: $13.23
Taxable Value: $31,421.00
Sr. Exempt: $0.00
Sr. Taxable: $0.00 Total Tax: $574.45
http://apps2.coj.net/pao/printver.asp?ReNum=171058+0050 1/19/2006
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Oa BUILDING AND PLANNING 17 MAR 2006P• f.�' t,''•
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' ' ' ' Atlantic Beach,Florida 32233-5445 '___f { ;i!';t i� i ?1 _'' l:YE (ATI' .'+ ' .
„,` .► • '• 0004611985 MAR 17 2006
'"rF If `• '' , MAILED FROM ZIP CODE 32099
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OT n _ Raymond and Gladys Marrero
DO K C S S 831 Begonia Street
1 S Atlantic Beach, Florida 32233
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CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
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ATLANTIC BEACH,FLORIDA 32233-5445
t TELEPHONE: (904)247-5800
V. " s) FAX:(904)247-5805
7)),M l-r SUNCOM: 852-5800
/ www.coab.us
March 16, 2006
Raymond and Gladys Marrero
831 Begonia Street
Atlantic Beach, Florida 32233
Re: Abandonment of septic tank and connection to sewer service
Dear Mr. and Mrs. Marrero:
Based upon the information you have provided with your application, you are eligible and have
been selected to receive financial assistance to convert from your existing septic tank to City
sewer service. The City will use a portion of its Community Development Block Grant funds to
fund the actual connection to your home,the tap fee and the impact fee. -
You will first need to obtain estimates for the work and then provide these to the City. The City
will need at least two estimates from a plumber or contractor licensed to do this type of work.
The City will coordinate with you to select one of these. The contractor will then be in touch
with you to schedule the work. I will need a copy of any agreement with the contractor or
plumber that you sign authorizing the work to be performed. The plumber will be reimbursed
directly from the City once the work is completed and inspected by the City. Please be sure that
your plumber has obtained the required permits prior to commencing any work. Before the work
is begun, the enclosed Agreement with the City will need to be completed, signed by you and
notarized. You may request estimates from any properly licensed plumber you wish. The City
has used Gruhn May, Inc. to do a number of these conversions, and I have provided their contact
information below. You are not required to use Gruhn-May, but they are familiar with the
process, and you might consider getting one of your estimates from them.
I want to be sure you understand the terms of the funds that will be used to do the work. The
funds are a combination interest-free loan and grant. You will be required to sign the enclosed
Agreement with the City for the dollar amount of the work. The amount of this "loan" will be
reduced by ten percent every year. In other words, at the end of ten years, you will owe nothing
back to the City. But, if for any reason during that ten years, you should have to sell or rent your
house, the balance of any money due at that time would have to be re-paid to the City. Also, in
the event of your passing during the next ten years, likewise, the balance of any money due at
that time would have to be re-paid to the City if the house was sold, or if the house goes to your
Page two
Mr.and Mrs. Marrero
March 16,2006
family and they wish to keep living in the house, they would have to meet the low or moderate
income requirements and sign a agreement for any remaining balance. I will be glad to answer
any questions you may have, and may be reached at 247-5826.
Sincerely,
Sonya D err, AICP
Community Development Director
Gruhn May , Inc.
6897 Philips Parkway Dr. North
Jacksonville, Florida 32256
(904) 262-9544 Fax 268-0679
Enclosure
cc: Chris Walker, Department of Public Utilities
Donna Kaluzniak, Director of Public Utilities
SEPTIC TO SEWER
CONNECTION AGREEMENT
CITY OF ATLANTIC BEACH,
COUNTY OF DUVAL, STATE OF FLORIDA
For the value of services received, which may include, abandonment 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 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. Said sum shall bear no interest
and shall be reduced in amount at the rate of one/tenth (1/10th) per year, on each
year anniversary of this Connection Agreement, until reduced to a balance of zero
(0) dollars at the end of ten 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 ten (10) 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: Date:
Signature of Maker:
SWORN AND SUBSCRIBED BEFORE ME THIS DAY OF
STATE OF FLORIDA, COUNTY OF DUVAL
NOTARY'S SIGNATURE
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