2602 BAKER AVE 2022-04-12 - Laserfiche WebLink

Backwater Frevention Device Rebate Program Rebate Application Form _--- —/� --- _ — --- -_ --- Property Owner Name _� V URk�lr Ae r"l��+��t o�lJ h_N �� --- Instaliation Address. ��D a �Q.�C_�V� City: �_�J�.E � _____ State �s�y,�_Zip�_ � 8 x a_�— IMailing Address(il diflerenl): _ ,�i��0� � Q kN.h,...�ve- ---- Cir r �q,G�— — State' ��-_ZiP: q �`�. 4 � [mail �j�hc�lnu{11EIL�l.°UJx�4.G_�' • he{ Phone (7(1�' ✓`- �R- �l .'LO1 Tota� Cost lo Install Device (f�om :ontractor invoice): $_fJ�4 U�� 3� Please verify the foilowing: �m the owner of the property where the backwater prevention device was installed. _ I �vorked wilh the ccniraclor lo determine the location for the backwater prevention dev�ce and undersland that fhe decision regarding Ihe localion of�he device was mine. ��y contractor instructed me how to access, inspect, and mainl3;�� the device. [�I�Understand that I am responsible for mamlammg thr. backwater prevention device and keeping it in good working order, unless it is installed in the cily nght-of-way �sell my property, I will make potential buyers aware of the backwaler prevenlion device and the need to inspect and maintain il on a regula�basis �j I am enclosine�all of the ner.essary paperwork (use the yellow Rebale Submittal Checklist) Select from the following: (.] The r.nnlr:�clor idenhhed downspouls or c4her drain�ge Ihnes Uiat were connected lo my sewer line tween my house and the instatled devir.e) and removed, or rerou�ed lhem. � To my knawtedge, my property has no downspouls or olher drainage connected to my sewer line (between my house and the inslalled devicej. [ � The�e are downspouts or other dramage hnes connecled to my sewer line(between my house '" and Ihe inslalled device) I underst�nd lhal leaving lhese r.onner,tions creates a risk of flooding and I accr�pt that risk. Slgnature�; �1 lAate �• /� / �