Laserfiche WebLink
�,. <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: ���N v � `* <br />, �� e w; <br />Installation �ddress: S! 0 �' (oc-r3y /�-u� <br />ciry: �vE,�'E,-r- State: G</I�— Zip: 9ff�3 <br />Mailing Address (r(drfferent): <br />City: Slate: Zip� <br />Email: Phone: �Z� ZS Z / �i�� <br />Total Cost to Install Device (Irom contracforinvoice): S �,�� "!� ��� <br />Please verify the following: <br />�.] I am the owner of the property where the backrrater prevention device was installed. <br />� I worked �vith the coniractor to determine ihe IocaUon for ihe baclovater pre�:cr�iion dee•ice and <br />understand that the decision regarding the location of the device was mine. <br />[� My coniractor insWcted me how lo access, inspect, and maiMain the device. <br />I understand Ihat I am responsibie tor rnainlaining the backwater prevention devicti and keeping <br />it in good working order, uniess it is installed in the city right-ot•v�ay. <br />[�j If I sell my property. I will make potential buyers aware of Ihe backwater prevention de•nce and <br />the need lo inspect and maintain it on a regular basis. <br />[�} I am enclosiny all of the necessary paperwork (use Ihe yeliow Rebale Submittal Checklisq. <br />Select trom the tollowing: <br />[�i llic contractor idenlified downspouts ar olher drainagc Ilines thal wcrc connecled lo my sewer <br />line (behveen my house and the installed devlce) and removed, or rerouted ihem. <br />❑ To my knowledge, my property has �o downspouts or olher drainage connected to my sewer line <br />(belween my house and Ihe installed device). <br />❑ There are dovmspouts or other drainage lines connecled lo my sev�mr line (behveen my house <br />and lhe inslalled device). I undersland Ihat Ieaving ihese connec0ons creates a risk of Oooding <br />and I accept Ilial risk. <br />Sigrtatwe �— `) V `'`" ��� Date � � z' � � � S <br />! <br />