Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> E� ,T Rebate Application Form <br /> Property Ovmer Namr.: !/l' ✓' �+ �/�'"� _ <br /> Installation Address: ��-� ��'`�� ��""� _ <br /> � <br /> City:��_--State: li✓� Zip:�� <br /> P.1ailing Address(i(di((erent�: _ <br /> Cily: ;� � ; C 1 �' State: Zip: <br /> I ' <br /> ; EmaiC_ � G✓ - �N�_G���Co� Phone: (71')_ ���y 1L I <br /> � Tolal Cost to Inslall Device (lrom conlractor invoiceJ- 5� ��9 — — I <br /> ! J <br /> Plcase veri(y tbe following: <br /> fI am the orrner o(the prope�ty�ahere the back::�ater pr�vention device tivas installed. <br /> L, I worked �:-ith fhe contreclar:o detennine ihe localion for ihe bac'iv.�ater prevention device and <br /> understand lhat the decision regarding the location of Ihe device�vas mine. <br /> ❑ �vty conlraclor ins?ructed me how to access, inspect, and maintain the device. <br /> ��ndersland that I am responsible for mainlaining the backwaler prevention device and keeping <br /> it in good�.vorning order, unless it is installed in Ihe city ric�ht-of-e�ay. <br /> v7�lf I sell my property, I e�ill make potent al buycrs awarc of thc backwater pre��ention device and <br /> the need to inspect and maintain il on a rcyular basis. <br /> (�im enclosing all of the necessary papenvoik(use Ihe yellow Rebate Suf;ni.Ual Checkl�st). <br /> Scleet from thc following: <br /> ;�The contractor idenli6ed doa:nspouls or olher Arainac�e Ilines�hal�vme cnnner,ted to n-y sr.::�er <br /> line (betwcen my house and ihc in�,ta�led device) and removr.d, or rerouted them. <br /> [� To nry knowledge, my properly has no do�:�nspouls or other drainoc�e connected to my se�^er tine <br /> (beN�een my house and the installed devicc). <br /> (��here are dovmspouts or'Oiher drainage lines connected to�ny sewer line (behveen my house <br /> and the installed device). 1 undersland ihat leaviny these connetlions creales a risk of flooding <br /> and I accept that risk. <br /> �— / i <br /> , � /� �, � <br /> Signature /� � Date__�//,�—'t � <br /> / � <br />