Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installalion Address: <br />Cily: C�!%.2Z Slale: C�.%A z�p: 9��1 a�' <br />Mailing Address (il diRerenQ: <br />City: State: Zip: <br />Email: J�G /���?�i1�7{/ Ceih Phone: �'j o%377- �'iTr� <br />Total Cosl lo Inslall Device (Irom contractor invnice): $ r"7-t'C1% • S l� <br />Piease verify the following: <br />� am the owncr of the property where the backwater prevenlion device was installed. <br />v�l worked wilh the conlraclor to determine lhe location for the backwater prevention device and <br />undersland thal the decision regarding lhe location of the device was mine. <br />[� My contractor instructed me how to access, inspect, and mainlain the device. <br />t, I understand ihal I am responsible (or maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in thc cily right-of-way. <br />�If I sell my property, 1 will make polenlial buyers �ware of the backwaler prevention device and <br />lhe need lo inspect and maintain il on a regular basis. <br />i�! am enclosing all of lhe necessary papenvork (use the yelloN Rr.bafe Submillai Cliecklisl). <br />Scleet rom the following: <br />The contraclor idenlified downspouts or other drainage Ilines that were connecled lo my sewer <br />line (belween my house and lhe inslalled device) and removed, or rerouted Ihem. <br />❑ To my knowledge, my properly has no downspouls or other drainage connected to my sewer line <br />(belween my house and the installed device). <br />❑ There are downspouts or olher drainage lines connected lo my sewer line (belween my house <br />and Iho inslalled device). I undersland thal leaviny these conneclions creates a risk of flooding <br />and I accept ihat risk. <br />Signature C� �-�-�^�'-� Date T �✓' �LT <br />