500 ALVERSON BLVD 2022-04-12 - Laserfiche WebLink

_. . - - - -- - - -- ---- -- --- - - - - - -- _- - � --- • . i Backwater Prevention Device Rebate Program j R�bate Application Form I I I I � PropertyOwnerName: W � I`��'� � lJL��U� �0 �� __ , Installation Address:�dU ��—VG�S��v rJ� V b I `/ qgZ�l I City: �Y �1��% � State: _ W A" Zlp: I � , Mailing Address(f/diHerent): I City: State: _Zip: , Email: Phone: ( ) i — � Total Cosl to Install Device(/rom confracfor invoice�: $ _ I � Please veri`y the following: I (� I am the owner o►ihe property where the backwater prevention device was installed. I [� I worked with thc coNractor lo determfne the location for lhe backwater preventlon device and understand that lhe decision regarding.the location of Ihe device was mine, � �My conlractor instrucledime how to eccess, Inspect, and maintain•the device. I �/Punderstand,that I am responsible for maintalning the backwater prevenlion device and keeping j it In goad working order, unless It Is installed in the city right-of•way. ' , � � f Ilsell my propeAy, I will make polentlalibuyers aware oi ihe backwater preventlon device and �he need to Inspsct and�malntalnilt on a regular basis. j I I am enclosing all'of.lhe necessary papenvork(use the yellow Rebate Submittal Checklist). i Seleet(rom the following: L] The contractor idenlified downspouts cr olher dr�inage Ilines that were connected�o my sewer + line(hetween my houso and tho installed device)and removed,or rerouted lhem. : i ❑ To my knowledga, my propeAy has no downspouts or o�ner dralnage connected lo my sower lino �etween my house and the Inslalled dovice). here are downspe��ts or other dralnage Ilnes connected to my sawer Ilna(behveen my houso and the installed device). I�understand lhal leaving these conneclions creates a risk of Ooodinc� and I accept that risk. i S(gnarure � ' oate I — ��- (� � I I � I