Laserfiche WebLink
� �ackwate� �'revention Device Rebate Program <br /> Rebate Applica4ion Form <br /> ,— — ---- ------ --, <br /> � I <br /> Propedy O�vr,er Name. x� lvC���� � <br /> i r � <br /> : Ins!allalion Address �\� \�2�''J� '��' I <br /> �� W � Zi � <br /> � City: Cvc� —�..L��\ State. P � `�1 <br /> �' \taihng Address(d dillerenp. i <br /> II C�Iy: State' Lp. <br /> IEm3i1�.�-�-Yc.� .�1%�T� c-+ w�� (-C�"�'� PhOnO (�RS} T STI .Cq�3 .'c <br /> i / <br /> Tota1 Cosl lo Inslall Device(!rom con raclor invo�co). 5 <br /> f'Ic�•vcrify thc following: <br /> L•J ��m U�e cwcor ot the omperty where lhe backwaler prevenhon device wa,insta:ietl <br /> ;] I�v0�ked:vilh the conlraclor to delermine Ihe lotahon for�he Gackv+ate�p�evCnP,�n dev�,Ce an❑ <br /> �n0erstand Ihal the tlec�sion regartl;ng ihe ioa�lion o(the device was m:ae <br /> � j tdy controclar instruUed ree ho�N lo access,inspecl,and mamtain ihe tlevrce <br /> �I I understantl Ihal I am respon,i6le for mainla�mng the backwaler prevenlion dev�ce and Meep���y <br /> �t m good vro�king ortler,unless i:is inslailed m thc city ri9hPol-way. <br /> [� II I sell my pmperty.I wdl make pntent�al huye�s aware of lhe bacfcwater prevenlion�evice anC <br /> ihe need to inspect�nd mamtai�n on.rcgular hasi; <br /> �] I am endos�ng TII of Ih!•necessa�y pa;e�woi�(use R'.c ycPcr�ftebale Su�m�ttal Cher.YhSq <br /> Sclect Irom the followmg�. <br /> ,[]�The eonuaWor itlenuned dc;�rspmr-.ei n0�r.r Aiai�;qc li n��;iP:i�•::ru•�.:unnecied;u my se::e. <br /> Ime(hM�veen my h..use;md Ihc roslaPed dev�,u•).����1 icu',:,wt;l.�,r�rmulr�Ihem <br /> I.I To my know�ed9r..my property has r.o dorrnspouls or ol�ei diainage connecle;l to my sewe�r�ne <br /> (beh•+een my house and Ihe installed devir.e� <br /> �- Tnrre are downspoul,or othei dramage I�nes connected lo my sr�n�er Ime(bervmen my!�ouse <br /> :md IPi���nsta:led devr..e) I undersl:tnd Ihal lcaving Ihrsc conim.lions f.tea;e5 a ris4 0l Oondirg <br /> .�nA I.: '�.pl thal nsk <br /> r"�'�.) " . ,� ' <br /> __,�_--.- -� o�t� � �_ : . � �_ <br /> s�r�n.,rur�—�-��_---- — — – — <br />