1314 COLBY AVE 2022-04-13 - Laserfiche WebLink

--- - ... - - -� -- - - - ---- -- ------ -- - -- - - - - - - - �`�_: - - Backwater Prevention Device Rebate Program �F„ Rebate Application Form Property Owner Name:��trl .t /�v1v� �QIV YY1 DYlO' InstallationAddress: ��4- C.o�b� ' -�llf City: E�{�C�.}'�- State:!A1�4 Zip: a�201 Mailing Address (il differentJ: �(LWLP, Ciry: State: Zip: Email: Y/AYL��C,dldl,l�,p ar�1 � Wi_Phone: (�25� 2�Z-OIBOI Total Cost to Install Device (Irom contraclorinvoice): $ Please verify the following: �I am the owner of the property where the backwater prevention device was installed. �I worked with the contractor lo determine the location (or lhe backwater prevention device and understand that lhe decision regarding the location o(lhe device was mine. . � My conlraclor inslructed me hovr to access, inspect, and maintain the device. � I understand that I am responsible for maintaining the backwater prevention device and keeping il in good working order, unless il is instailed in lhe city right-of-way. �if I sell my property, I will make potential buyers aware of the backwaler prevention device and the need lo inspscl and maintain it on a regular basis. � I am enclosing all of the necessary paperwork (use Ihe yellow Rebate Submittal Checklisl). Select from the following: ❑ The contractor identified downspouts or other drainage Ilines lhat were connecled to my sewer line (between my house and the installed device)and removed, or ierouted ihem. � To my knowledge, my property has no downspouts or other drainage connecled to my sewer line (between my house and lhe inslalied device). ❑ There are downspouts or olher drainage lines connected to my sewer line(between my house and lhe inslalled device). I understand lhat leaving these connections creates a risk of flooding and I a�cept Ihal risk. � Signatuie�FJ;,, �( (J�n.,»,m.LL Date G ��is