1002 COLBY AVE 2022-04-13 - Laserfiche WebLink

i __ .- --- - -� -- � ..___-- -- - - - ---- - ---__ _ _�_�_---.. . --- - -- -- - -- � I'� ntion Device Rebate Pro ram Backwater Preve 9 Rebate Application Form ;' Property Owner Name: AY'1�o �� U1�^'t7S �1 Inslallalion Address:� ��o�- ��N ��"� - — City:�Y'�'Q-� State: b✓/� Zip: � g o�-� � �vtailing Address(i(diHerent): i City: Stale: Z�P ' Email: �r^�"i� � �� ! �"� . �v"i Phone: (4y5) �SZ- S6 � Total Cost lo Install Device ((rom confractor invoice): 5 J�-��• � I � Please verify lhe following: � I am the owner of the property where lhe backwater prevention device was installed. � [�( I worked wilh the contractor to determine the location for the backwater prevention device and understand that the decision regarding the location oF lhe device was mine. �" My contractor instrucled me how to access, inspect, and maintain the device. � g I understand that I am responsible for maintaining Ihe backwater prevention device and keeping it in good�vorking order, unless it is instalied in the city right-ot-way. � � If I sell my property, I will make potenlial buyers aware ot the backwater prevention device and the need to inspect and maintain il on a regular basis. � I am enclosing all oi the necessary papeiwork (use lhe yellow Re6ale Submittal Checklisl). Select from the following: I � [� The confractor identi(ied downspouts or other drainage Ilines that were connecled to my sewer � line (belween my house and the installed device)and removed,or rewuled them. � � To my knowledge, my property has no downspouts or other dreinage cor•+�ecled fo my sewer line � (between my house and ihe inslalled device). i ❑ There are downspouts or other drainage lines connected to my sewer line (between my house and the inslalled device). I understand that leaving these connections creates a risk of flooding � and I accept that risk. � Signature �Oate �I � � < (� �