1121 GRAND AVE 2022-04-15 - Laserfiche WebLink

Backwater Prevention Device Rebate Ip gr.��Il�� Rebate Application Form ^� �� �� idY 0 6 2015 U Property Owner Name: �� Installalion Address: � � Z-1 C�12c�n�0 (��f E City: Cv �c6-' G T'T State: WE'+ Zip:�2.a � Mailiny Address(i(different): City: State. Zip: _ Ema��: �o�,.�caa.o. C:,u ETCE �i•1 oT.nA,�,��''�Phone: (Z) 3'��'I N I �� Total Cost lo Install Device (from contractorinvoice): S Z`-j 5 7 OK (o fwo�.y�k c, RTS Please verify the following: \ IZ'�`,a. do...i 1�] I am the owner of the property where the backwater p�evention device was installed. �it�,,, kr,.�o11/ a S/s�/rf �[I I worked with the coniractor to determine the location for the backwater prevention device and understand that the decision regarding the location of the device was mine. � A4y contractor instructe� me how to access, inspect, and maintain the device. �] I understand that I am responsible for maintaining ihe backwater prevention device and keeping it in good working order, unless it is installed in lhe city right•of-way. � If I sell my property, I will make polentiat buyers aware of the backwater prevention device and the need to inspect and maintain il on a regular basis. � I am enclosing all of the necessary paperwork (use lhe yellow Rebate Submitlal Checklist). Select from the Toliowing: ❑ The contractor idenhhed downspouts or olher drainage Ilines that were connecled to my sewer line (between my house and the installed device) and removed, or rerouted Ihem. '�[] To my knowledge, my property has no downspouts or other drainage connecled to my sewer Gne (belween my house and lhe installed device). p�,..•�3�o�� c�,.-� N�c.rg pv��-�r¢ft-�,,. a � �9Pc.l«�ov �lla�.vE-. 'SE-F ,-V-,(�"P ❑ There arc downspouts or olher drainage lines connected to my sev�er line (belween rny house and the Installed device) I unde�s'and th�t leaving these conner.Hnns creates a�isk ef floodinq and I accept that risk. ..�—� � Signature .i-�_� Date L Z 4 /S�