1223 COLBY AVE 2022-04-13 - Laserfiche WebLink

Backwater Prevention Device Rebate Program Rebate Application Form PropertyOwnerName: e��l,�e �'"��n,,..� /� r;sfi�e f70�YL.uL— . dba �in..,o,.c� l/eniw'eS LLG Installalion Address: �. -i � �� h.. ,4..e - U�I P-x - _ City:�u�re�L-t State: IiJA ' _Zip:_-rl $Z�i Mailing Address (i(diflerenf): �Q jp�yf� ncL G1G( city��1�� state: �,)R z�P: q8 zn3 [mailc�p_�ymnBP•�#;r,��i�an�-ie�cam—Phone: Iy2Q 3lq Z4le B K��6'�'r n e. Total Cost to Ir.stall Device (from contraclorinvoice): S r�FSZ�� Please verit�the following: ❑ I am the owner of the properly where lhe backwater prevention device was installed. ❑ I worked with the contractor to delermine lhe location for the backwater prevenlion device and understand that lhe decision regarding lhe location of the device was mine. ❑ My contractor instructed me how to access, inspect, and maintain lhe device. ❑ I understand that I am responsible for maintaining the back�vater prevention device and keeping it in good working order, untess it is insfalled in Ihe city right-oi-way. [] I(I sell my property, I wil! make polential buyers aware of:he backwater prevenlion device and the need to inspect and maintain It on a regular basis. ❑ I am enclosing all of Ihe necessary paperv�ork (use the yellow Rebate Submittal Checklist). Select irom the following: ❑ The conlraclor idenhfied downspouts or olher drainage Ilines lhal were connecled lo my sewer line(between my house and ihe installed device)and removed, or rerouted them. ❑ To my kno�vledge, my prop=rty has no downspouls or other drainage connected lo my sewer line (helween my house and the inslalled device). ❑ There are downspouts or olher drainage lines connected to my sewer line (between my house and the inslalled device). I understand that leaving lhese connections creales a risk of Ooodinc� and I accept lhat risl;. ' Signature�✓ 1�� Date y -Z � -� � 7