240 ALVERSON BLVD 2022-04-12 - Laserfiche WebLink

i I � /^,�}� Backwater Prevention Device Rebate Program �� Rebate Application Form I I Propeny Owner Name: _��(,�t2.� {C�w-'11 _____ I Installalion Address: _ � �,�/�1j1-SO�V�LII� _ Cily: ��F'i(( Slale 1^�� Zip: 9�_�.O � � � Mailing Address (il dilleren(J: � City: Stale Zip: I Email: _Phone: (�Z}'j_J$��(_�U ! Total Cosl lo Install Device (Irom contracfor invoice)� $_�y,�. � __ _ � --- - - .. - ---- ---- _ ._. ---- --- -- - ' Pleasc verity the following: I �.1 am the owner of the property where lhe backwater preventi:,n device was mstalled. I � I worked with lhe contractor to determine the location for the backwater prevention device and understand ihat the Aecision repardin�the location of the device was mine. (�.My conlraclor instructed me how lo accoss,inspect, and maintain the device. �I understand thaf I am responsible for maintaining the backwater prevention device and keepmg it in good workinc�order, unless it is insla0ed in the cily right-ol-way. � �It I sell my propeAy, I will make potenlial buyers aware ot Ihe backwaler prevonlion device and Ihe need to inspect and maintain it on a regular basis. � �I am onclosing all of the necessory paperviork (use the yello�v Rebate SubmiUal Chocklist). Select from lhe following: � ❑ The contractor identilied downspouls ar oQier drainage Ilines that were conneGed to my sewer line (belween my huuse and ihe installed device)and removed, or rerouled them. ! o my knowledge, my property has no downspouls or othor drainage connecled W my sewer tlne ' �be6ve�n my house and llie inslalled device�. I � � There are downspouts or o�her drainage �ines connected to my sewer line(between my house � and the installed devicci). I understand that leaving theso connnctions creales a nsk of Oooding � and I accept that risk. Slgnature_ Date