Laserfiche WebLink
i <br /> Ba�ckwater Prevention Device Rebate Pro,�ram <br /> Rebate Application Form <br /> PropertyOwnerName: YI Il.lrV(y1 V� (_aZa�.le.2- <br /> Installation Address: b � O� � � <br /> City: � �12r Slale� Zip:��v 1 <br /> Mailing Address(il difterenQ: X 10� Z��'�' � �1P. 1�' � <br /> City: ��1./ � State:�_Z�P: q�a� 1 <br /> Email:�.��� RBC�h L��lML1 I f ���hone:36> �53 - 3�9� <br /> Tolal Cost lo Install Device(Irom contraclor invoice): $�.� �c i : `� <br /> I <br /> Please,erify the following: <br /> �am�lhe owner of the properly where lhe backwater prevenlion device was installed. <br /> �worked with the contractor to determine the location for lhe backwater prevention device and <br /> undersland that lhe decision regarding lhe location of the device was mine. <br /> � �ly conlractor inslructed me how to access, inspect, and.maintain the device. <br /> []/�understand thal I am responsible for maintaining the back�vater prevention device and keeping <br /> it in good working order, uniess it is inslalled in the cily right-of•way. <br /> �I sell my property, I will make potenlial buyers aware of lhe backwaler prevention device and <br /> the need to inspect and mainlain it on a regular basis. <br /> �m enclosing all of Il�e necessary papenvork(use the yellow Rebate Submillal Checklist). <br /> Select irom the following: <br /> �� The conlractor identified downspouls or other drainage Ilines thal�vere connected to my sewer <br /> line (between my house and lhe installed device)and removed, or rerouled them. <br /> ��To my knowledge, my property has no downspouls or olher drainage connected to my sewer line <br /> (between my house and the inslalled device). <br /> ❑ There are downspouts or other drainage lines connecled to my sewer line(between my house <br /> and the inslaUed device). I undersland that Ieaving these connections creales a risk of flooding <br /> and i accept that risk. <br /> Signature �Date �� <br />