Laserfiche WebLink
�� <br />Backwater Preventioii Device Rebafie Proyram <br />Rebate Applic�tion Form <br />Property Owner Name: <br />Installation Address: <br />/ <br />City: �� r. ✓� e. � State: �%�_ zip: ��e2 0 3 <br />f �ailing Address (if diHerent): <br />City: <br />Emall: <br />State: <br />Total Cost to Instail Device (lrom contractor invoice): $ <br />Please verify the following: <br />Zip: <br />Phone:( <br />� I am the owner of the property where lhe backwater prevention device was i�stalled. <br />❑ I worked with the contractor to detertnine lhe localion for the backwater prevei�lion device and <br />understand that the decision regarding the location of the device was mine. <br />❑ My contractor instructed me how to access, in�pect, and maintain the device. <br />❑ I understand that I am responsible for maintaining the backwater prevention device and keeping <br />il in good working order, unless it is installed in the city right-oF-way. <br />❑ If I sell my property, I will make pofential buyers aware ot the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />❑ I am enclosing all of the necessary paperwork (use the yellow Rebale Submittai Checkiist). <br />Select (rom the following: <br />❑ The contractor idenlified downspouts or other dralnage Ilines that were connecled 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 downspouts or other drainage connected to my sewer line <br />(belween my house and the installed device). <br />❑ There are downspouts or other drainage lines connected l� my sewer lina (belween my house <br />and lhe installed device). I understand thal leaving these connections creales a risk of flooding <br />and I accept that risk. <br />Signature / Date �%� � � <br />l / <br />