1312 COLBY AVE 2022-04-13 - Laserfiche WebLink

i � � /,�� Backwater Prevention Device Rebate Program , �,�� Rebate Application Form � . ,-- - -- ; ��i Property Owner Name: V� �r.yL c.l II Inststlation Address: �3 1 ��b ��i.�Q`��2._'�� City:�_�/Q,(�"�- State:�Zip:9�� I h9ailino Address(if diflerenff: � I City: _ State _ Zip: I Email � Fhone:(� 6�3 � �Q � I Total Cost lo Inslall �evice((rom conMaclor invoice):S�,f�-�c../ � �— Plcasc vcrify the following: ' , �am Ihc owner of the property�a�here the backwaler prevention device was inslalled. � �� (zi I �vorked wilh the contraclor to deterrnine the location for Ihe backwater prevenlion device and ' undersland thal lhe dec'sion regarding lhe localion of Uie device�vas mine. � i � �Jy con(raclor instructed me how to access,inspecl, and mainlain Ihe device. ; � j I undersland that t am responsible for mainlaining Ihe backwater prevenlion device and keepiny � � it in good working order, uniess it is installed in the c�ry right-of-u•ay. � �� if I sell my property, I will make potenlial buyers aware of Iho backwaler prevention device and lhe necd to inspect and maintain it on a regular basis. i �j I am enclosing all of Ihe necessary paperuork(use the yellow Rebate Submittal Checklist). � , Seleet irom the followin�: ; � ) Tho coMraclor idenlified dowrspouls or olher drainage Ilines thal were�connecled to my sewer � line(between my house and!he insl�lled device)and removed,or rerouted them. �"�To my knowledye, my property has no downspouis or other drainage connected lo my sewer line � (belween my housc and Ihe installed device). i I � There are downspouls or other drainaga Imes connected lo my seH�er line(between my house ' ard Ihe installed dr.vicr.). I urdeistand Ihal ieavin�Ihese connections creates a risk ol flooding ;ir.d I accept lhat risk ! � � � Signature � Datc� � '� � I i � i I ;