Laserfiche WebLink
Backwater Prevention Devic.� Rebate Program <br />Rebate A�p(ication Form <br />Properly Owner Nam�: �' I�� rI lv f 2 i T z c- <br />Installation Address: �-' p� C v L_ Q� .q Vt� <br />City: L' ��/� �/� State: W� Zip:_ ��c�� � <br />Mailing Address (i/diHerent): <br />Cily: <br />Stale: <br />Email: r a�-� . i�ri �z ��C'����^c.a�%+tN"�- Phone: (Y�S7 .757- OG �%�f <br />Tolal Cost to Inslall Device (l�om conlracforinvorceJ: S��'� L• a� <br />Please veriFy the following: <br />� I am the owner of the property where the baek�vater provention device was installed. <br />[] I worked wilh Ihe conlractor lo delermine Ihe location for the backwater prevenlion device and <br />undersland lhat lhe decision regarding lhe location oF the device was mine. <br />] My conlractor instructed me how to access, inspect, and mainU3in the device. <br />[� I undcrstand Ihat I am responsible for maintaining lhe backwaler prevenlion devico and keeping <br />it in good �vorking order, unless il is installed in the cily rigtit-of�u✓ay. <br />� If I sell my properly, I wlll make polential buyers aware oi the backwaler prevenlion device and <br />lhe need to inspect and maintain il on a regular basis. <br />� S an� enclosing all of the necessary pape�work (use the yellow Rebale Submillal Checklisl). <br />Sei^t: from the following: <br />❑ The contractor identified downspouls or olher drainage Ilines thal wore connected to my sower <br />Iinc (belween my house and the inslalled devicA) and removed, or rerouted Ihem. <br />❑ To my k�owledge, my property h�s no downspouls or olher drainage connecled fo my �:ewer line <br />(belween my house and the inslalled device). <br />� Thero are do�vnspouts or olher drainage lines connecled lo my sewer line (between my house <br />and lhe installed devico). I understand Ihat leoving Ihese conneclions creales a risk of tlooding <br />and I accepl that risk. <br />� � <br />i . - �-- <br />� � / Dafe �`��- US--3U/S <br />Signalure � ... • � <br />� " � <br />tr.,. +� <br />