Laserfiche WebLink
1 - <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> I 1 <br /> Property Owner Name�� � � � � '�- �������� �� �,���/ <br /> [� I <br /> ' Instailalion Address: �3 ��� .� � � , ' 1 L'� I <br /> L v�,� (� ���01--1 �OI d� <br /> City:�V '�� �-�I Slale: Zip' _ <br /> IJlailing Address(il diNerent): � <br /> Ciry State: Zip: _ <br /> Email. r.,a���,} �c `��1,� `Lp+tic0.ft. /l� Phone�`(1�} �S�3`3 ar <br /> �T <br /> Total Cost to Inslall Device (from confractor invoice): $ <br /> Please verify the following: <br /> --`a] I am the owner of lhe property where the back�vater prevention device�vas installed. <br /> � ' -�] I worked wilh lhe conlractor to determine the location for the backwaler prevention device and <br /> j understand that lhe decision regarCing lhe location of the device was mine. <br /> i <br /> �;� Idy contraclor instructed me how to access,insFect, and maintain lhe device. <br /> ��;;j] I undersland that I am responsible for maintairnng the backwater prevention device and k.:eping <br /> it in goad working order, unfess it is inslalled in Ihe city righl-oi-way. <br /> ���V� It I sell my property, I wlll make potential buyers aware ot Ihe backwater prevention device and <br /> the need to mspect and maintain il on a regular basis. <br /> �� I am enclosing all,of the necessary napenvork(use the ye!low Rebate Submittal ;,hecklist). <br /> Select irom the following: <br /> �_� The r.onUador identified downspouls or oQier drainage Ilines that were connecled lo my sewer <br /> line (behveen my house and lhe insl�lled device)and removed, or rerouled lhem. <br /> �'(� To my kno�viedge, my property has no downspouts or otl:er draina�e connected to my sewer Iine <br /> (bchveen rny house and the mstalled device). <br /> I 1 There are downspuuls or alhcr drainage hnes conner.ted to my sewer line (betwcen my house <br /> and the mstalled device). I understand that Ieaving these connedions creates a risk of flooding <br /> and I accept that risk. <br /> i <br /> ..c'�-�v.�!,e2. / �,;.¢j� Date � ` .�_I �� <br /> Signature�--� `" � `"'--�,�— <br /> — '(1�I <br /> I <br /> I <br /> � <br />