Laserfiche WebLink
Backwater Prevention Device Rebate Pro.yram <br /> Rebate Application Form <br /> PropertyOwnerName: I`�4�J��% 2 � � 1��� <br /> InstallaGonAddress: 7�Z3 C���'v`I �r= <br /> c�ry: l�v��� state: CAJ A z�P: 9 8 7� 1 <br /> Mailing Address(il diHerent): I �I y Z7 � �J� l�C`�� �r <br /> City: ���2Y�.�n t� State: �Ps z�p: 9�3y - I � bo <br /> Email: �1s W�`-o� L' �.1V„ r,oM Phone: (42� �30 qI 73 <br /> Total Cost to Install DFvice(Irom confracforinvoice): $ .,���7-�� <br /> Please verify the following: <br /> �I am the owner of the property where the backwater prevention device was installed. <br /> �I worked with the contractor,tu determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> � My contractor instruded me how to access, inspect, and maintain the device. <br /> �I understand that I am responsible for maintaining the backwater prevention device and'keeping <br /> it in good working order, unless ft is installed in the city right-of-way. <br /> �If I sell my propeAy, I will make potential buyers aware of lhe backwater prevenlion device and <br /> the need lo inspect and maintain it on a regular basis. <br /> �I am enclosing all•of the necessary paperwork(use lhe yellow Rebate SuCmittal Checklist). <br /> Select from the fol�owing: <br /> �The coniractor identified downspouts or other drainage Itines that were connected to my sewer <br /> line(between my house and the installed device)and removed,or rerouted them. <br /> ❑ To my knowledge, my property has no downspouls or other drainage connected to my sewer line <br /> (between my house and the inclalied device). <br /> ❑ There are downspauls or olher dra�nage lines connecled to my sewer line(between my house <br /> and lhe installed device). I understa�id that leaving these wnnections creates a risk cf(looding <br /> and I accept that risk. <br /> Slgnature � Date � 2� v r � <br />