Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property Owner Name: � �V'Q �-o I'o t'� � <br /> Installation Address:.�� �o � f O A �.J u --+ <br /> Ciry: �VCJ`P.�_State:�Zip:��� � <br /> Mailing Address (if diBerent): �l�?i �� 11� � f <br /> City: �✓��"}''� State:�f_�zip: G ��.c� � <br /> Email: ��Q JeC.�h f'o `�-S � C-d1v�Cu,S�''p�{: ��,� r�-��� ���7 <br /> Total Cost to Inslall Device(frorn contrac�orinvuice): ,�O��D,W � 1�tx � ���`D <br /> o'�a� -�i �� D . D <br /> Please verify the following: <br /> �f I am the owner of the propeity where the backvaater prevention device was instalted. <br /> �I worked with the contractor to determine the localion for the back�vater prevention device and <br /> undersland that the decision regarding the location of the device vaas mine. <br /> �My contractor instructed me how to access, inspecl, and maintai�the device. <br /> �I understand that I am responsible for maintaining lhe backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> �If I sell my property, I�vill make potenlial buyers aware o(the bac��r�aler prevenlion device and <br /> the need to inspect and mainlain it on a regular basis. <br /> `�I am enclosing all ot the necessary papervuork(use the yr.liove Rebate Submiltal Checklist). <br /> Select from the following: <br /> ^-=�cf�7he conlractcr identi ied downspouls or olher drainage Ilines that were connected to m sewer / <br /> line(belween my house and the installed device)and removed,or rerouted them. `y v��^�GS71�4���l <br /> �1'o my knov�ledge, my property has no downspouts or other drainage connected to my sewer line <br /> (betvdeen my house and Ihe inslalled device). <br /> ❑ There are dow��pouts or other drainage lines connected to my sewer line(belween my house <br /> and the in�Ialled device). I understand that leaving these conneclions creates a risk of flooding <br /> and i accept that risk. <br /> Signature Date � �S^ � �/ <br />