Laserfiche WebLink
. i <br /> E <br /> I <br /> Backwater Prevention Device Rebate Program � <br /> Rebate Application Form f <br /> I <br /> i <br /> - — -- i <br /> Property Oe�ner Name: J l/t'/1 ���r�..i1�/ � <br /> � <br /> Inslallation Address: �� ;L��� ! <br /> aty:Y��°���r Stale: 1.✓9' Zip�Lof _ ' <br /> i <br /> Mailing Address (i/dillerenl): � <br /> i <br /> Cdy: Slate: Zip: <br /> Email: Phone: ( ) <br /> i <br /> Tolal Cost to Install Device(f�an conlrac�o�invorce): S Z,S� � � <br /> i <br /> i <br /> Please verify the following: <br /> [�j I am the o�vner o`Uie property�vhere the backwater prevention device was installed. i <br /> �j' I �vorked vaith the contractor lo determine the location for the backwater prevention device and � <br /> understand Ihat Ihe decision regarding ihe location of the devlce was mine. � <br /> CT] Ny contraclor mstructed me ho�v to access, insper,l, and maintain ihe device. � <br /> [�j I understand lhat I am responsible tor mainlalning the back�valer prevention devicP and keeping ' <br /> it in goad working order, uNess it is installed m the ciry right-oi-way. � <br /> ��] If I sell m•/ property. I will maAe polential buyers aware of the backwaler preveniion device and ' <br /> the need to insp� ct and mainlain i(�n a regular basis. i <br /> � I am enclosing all of the necessary papenvoik(use the yellow Rebale Submittal Checklisl). • <br /> � <br /> Select from lhc followinc�: � <br /> ❑ The conVactor identi(ied downspouts or olher drainac�e IGnes Ihal were connecled to my scwer i <br /> line (belween my housc and the inslalled device)and removed, ar rerou�ed lhem. <br /> � To my kno�vledye, my property ha,no downspouts or oUier drainage connecled to my sewer line '. <br /> (�et�veen my house and Ihe installed device). <br /> ❑ l here are downspuuls or olher drainage lines connecled lo my sewer I�r�e (bel�veen my house <br /> and Ihe installed device). I understand that leaving these connections creales a nsk of flooding <br /> and I accepl�hat risk. / <br /> � ' � �2��'� � "�' ; <br /> �, ��� ; <br /> '�.' -� �4;' J ) �. <br /> Signatu o- �' r ��� ' Date �' • �•' / •� <br /> ( G ri <br /> ..�� ✓C" , ,. <br /> i <br />