Laserfiche WebLink
i <br /> � <br /> ; <br /> i <br /> � <br /> : <br /> �� Backwater Prevention Device Rebate Program � <br /> Rebate Application Form <br /> — ----- — --- � <br /> Property O�ti�ner Name:�wr �.S -'h�c C S � <br /> � <br /> InstailationAdtlress _(p2A fQ�by A^+P j <br /> r � <br /> i aly:�Ur �eL-l- Stale. UJlf 2�p: 4�SZv 1 I <br /> i <br /> 'i Idaihng Adtlress(d drflerenl): ( <br /> City: �' State�. Zip: i <br /> i <br /> Email Phone: ( � <br /> � <br /> 1 otal Cosl to Insiall Device(!rom confrac!or invoice). S <br /> � <br /> � <br /> I <br /> Please veriry the following: � <br /> i <br /> [,J3 I am the owner of Ihe property whcre the bac4c�vater preven6on dev��ce was inslalled. ! <br /> i <br /> �y1 worhed with the contractor to determine the location for Ihe backwaler prevention device and � <br /> � understand thal lhe dension regardmc�lhe Iocalion of Ihe device was mine. , <br /> �;'t�ly contracfor inslructed me how to access, inspect, and maintain the device. i <br /> . , <br /> ��understand that I am responsible lor maintaining the bacbvater preventian device and keeping � <br /> it in good working order, unles5 it is installed in the city right-of•way. � <br /> f%J If 1 sell my prcperty,I wdi make polenual buyers awara ot the backwater prevention device and i <br /> the need to Inspect and mumtam d on a regular basis ' <br /> �i]I am enr.losiny all of the nr.cessary papenvork(use iho yeilov+Rebate Submittal Checklist). i <br /> Selec[Irom thc following� ' <br /> � <br /> �The contrar.tor idenhLed downspouts or other drainage Ilines Uiat were r.00nected lo my sewer � <br /> ' hne(beM�cen iny housr and Ihc inslalletl device)and removed, or rerouled them. � <br /> �j� To my knowledge, my property has no downspouts or clher drainago connected to my sewer hnr. <br /> �hetween my house and the installed device). � <br /> (-] There are downspo�ts or olher drainage lines connected to my sewer line(behveen my house <br /> and the:nstallod tlevice). 1 understand Ihat leaving Ihese conneclions creates a tisk of Oooding j <br /> and I accept�hal nsk � <br /> �� ' � <br /> � i <br /> � Z� �S � <br /> Signafure Date j <br /> ,.� ; <br /> I <br /> i <br /> i <br /> I <br />