Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> i Property Owner tJame: � J ^ 4.J �} �-LO t� <br /> � InstallationAddress: _ I SO � Cp I �Y <br /> City: E� �fe� State:,]��' Zip: ��do ) <br /> Mailing Address(il diNerent): <br /> Cily: Stale: Zip: _ <br /> Email: �LOf-�/� /1'I�1 � G /IOA/C. CoM P��one: (`��•zS�- 9Cos? <br /> Total Cost to Install Device ((rom confrac(or invoice): 5 �S�•� _ i <br /> � <br /> Please verify lhe following: <br /> �] I am,he ovmer of the property�•�here the backwater preventlon device was installed. <br /> �] I worked wilh•the contractor to determine Ihe location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> Ij�] My contractor instructed me how to access, insped, and mainlain the device. <br /> fri� I understand thal I am responsible for maintaining the back�vater prevention device and keeping <br /> it in good�vorkiny order, unless d is installed in the city right-of-way. <br /> [x] If I sell my property, I will make potential buyers a�vare of the backwaler prevention device and <br /> the need to inspecl and maintain it on a re�ular basis. <br /> T] I am enclosing all ot�he necessary paperc�oik (use the yellov: Re6ate Subnullal Chezklist). <br /> Select from the following: <br /> � J Thr. confraclor idenlilied dov;nspouls or olhcr �ii,iinage Ihnes tha� �:ere connor.tr.d t�� nry serr�r <br /> line(betv✓een my housc and the ins[alled device)and removed, or rerouled lhem. <br /> � To my knowledge, my property has no Aownspouts or other drainage connecled lo my selver line <br /> (between my house and the instafled device). <br /> � ] There are downspouts or olher drainage lines connecled�o my se�ver line (between my house <br /> and the installed device). I undersland Iha1 leaeing Ihese connections creales a risk of flooding <br /> and I accepl that risk. <br /> Signature,�7����- �`� Date � a / � <br /> i <br />