Laserfiche WebLink
� sackwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: �1 � 1 V � <br /> inslallation Address: �52� W I ✓� � I�C <br /> ��: ��e�- Ste�: J(�A-ZP: ��wi <br /> Mailing Address(ifdrNerenfJ: <br /> City: _ State: Zip: <br /> Ert�ail: �r `� _l���51 ,/�{it Phone:�Z) `3� '7Z-�D <br /> Total Cost to Install Device((rom confiactor invoice):$ <br /> Piease veNiy the following: <br /> I am the owner of lhe property where the backwater prevenGon device was installed. <br /> �worked with the contractor to detertnine the location for the backwater prevention device and <br /> understand fhat the decision mgarding the location of the device was mine. <br /> �y cont2ctor instructecf ine how to access, Inspeet, and maintain the device. <br /> �understand that I am responsible for mai�tair`^�the backwater prevention device and keeping <br /> It in good working order,unless It is installed In: �city rightof-way. <br /> �1 sell my property, I will make polentlal buyers aware oi the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> �am enclosing ail of the necessary papervvork(use the yetlow Rebale Submitfal Checklist). <br /> Select from the followinp: <br /> ❑ The contrector identified downspouts or other drainage Ilines that were connected to my sewer <br /> line(between my house and Ihe installed device)and removed,or rerouted them. <br /> [�T4 my knowledge,my property has no downspouts or other drainage connected to my sewer line <br /> (belween my house and the installed device). i <br /> ❑ There are downspouts or olher drainage lines wnnected to my sewer line(belween my ho��se � <br /> and the installed device). I understand that leaving these connecdons creates a dsk of flooding I <br /> and 1 accept that risk <br /> Signature !yl/�.��/I�lit.� Date �a'"(l � <br />