235 BRIDGEWAY 2022-04-12 - Laserfiche WebLink

�... -.. .:�.,. ._ ..:. -. _ ...._.. _ : . .. . _... . ... . . . . . II Prevention Device Rebate Pro ram � �� Backwater 9 �M��.,.... Rebate Application F�rm I _�.�„ ProperryOwnerNama:��; Kv�rK�a��Son (S�a'�1z�ur�t� I Inslallation Address: ,.,Z 3 S 7�� f, G F lJ�� Cily: r J n.✓b t'L __Stale:_�?- Zip: _ ��S otn( � Mailing Address(il diffe�enf): City: State: Zip: _ Email: C . ��yi� ( � .+� �i. com Phone:{�-�) 7�3-07'6 Tolal Cost lo InsUll Device(lrom contracforinvoice): $��!- 8cP Ploase veri(y tho following: �j I em the owner of the�proparty where the backwator pfeveNion device was inslalled. � I wortced�vith Ihe romrador to delormine Ihe locatian for Ihe backwater prevention device and understand that!he decision regardinp Ihe tocalion of Ihe device was mine. .�J My contractor ins��uciod mo how lo access,inspect, and maintain Ihe device. � 1 undersland thal.l am respon,i6le(or maintaining tha boc,kw.tor prevention device and keeping it in good workmg order,onless It is insla�led in Ihe ciry nghPo4way. [�, If I sell my property, I will make polenlial buyors awaro of lho backwaler prevention devica and the neetl lo inspect and me�ntain it on a regular basis. (� I am enclosing all ot ihe necessary papenvork(use the yetlow Robate Su6mitlal Checklist). Sclect hom the fallowing: '� The mnhactor idemitied downspouts or other drainage Ilines�h:�l were connr.cted lo my sevrer line (bv�vean my house and the inslalled device)and removed,or rerouted them. � 7o my knowledpc.my property has no tlownspouta or olher tlrainage mnnr.cted tq my sewr.r lina (beRveen my house and the installed device]. i' ❑ ihere are Aownspouts or other drainagu lines conneded to my sewer line(be�vecn my housc �� and Ihe inst�lled dovlce).I undersland Ihat leaving Ihese conneclions creates a risk ol Iloodiny � Iand I accepl lhal nsk. i i Sipnaturn �� fj �%tvr�i�-,.�rn� _ Date L - �- 10� r �II U ' � � � � � , � .