Laserfiche WebLink
0 Backwater Prevention Device Rebate Program <br />177 Rebate Application Form <br />Property Owner Name +Jrc<<r-e <br />rf <br />i 0 <br />Installation Address: 2 226 Ca <br />City- CVer¢ -fr State: ��1 Zip:_ Z03 <br />Mailing Address (if different): <br />City: <br />Email: <br />State: _ Zip: <br />Phone:( <br />Total Cost to Install Device (from contractor invoice): 5 <br />Please verity the following: <br />e-T am the owner of the property where the backwater prevention device was installed. <br />2-11 worked wilh the contractor to determine the location for the backwater prevention device and <br />undarsfand that the decision regarding the location of the device was mine. <br />[j My contractor instructed 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 It Is Installed in the city right-of-way. <br />(G'1f 1 sell my property, I will make potential buyers aware of the backwater prevention device and <br />tho need to inspect and maintain it on a regular basis. <br />(� I am enclosing all of the necessary paperwork (use the yellow Nobate Submittal Checklist). <br />Select from the following: <br />The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (between my houso and the Installed device) and ramoved, or rerouted them. <br />QCj To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />There are downspouts or other drainage lines connected to my sewer line (between my house <br />and thn installed device). I understand that leaving these cor ie:hons creates a risk of flooding <br />and I accept that risk. <br />Signature, Date <br />