Laserfiche WebLink
E3ackwater Prevention ��a �an Forrar�e Program <br /> Rebate App <br /> El� <br /> `��� -- � _ <br /> p�OwnerName� � � � <br /> Installation Address' ' �U x � ��"`– � u„. 1� <br /> Clty: �lU State: <br /> C� Zip, u� <br /> � Maihng Address (if di(Ierenl): <br /> 1 State. �_Zip'. <br /> i C�ty C� 5-Z�Z-37SZ <br /> Phone: ( � _.�— <br /> � Email: 2� c� c� ,��i <br /> ITotal Cost to Install Device (from conlracfor invoice) $ <br /> L - <br /> Please veriry the following: <br /> � I am Ihe owner o(the p�operty�Yhere lhe backv+ater prevenuon device was instalied. <br /> � � worked with the contractor to determine the location tor the backwater prevention device and <br /> understand that Ihe decision regarding the loca�ion ot the device was mine. <br /> [� 61y contreclor instructed me how to access, inspect, and maintain the device. <br /> � I understand that I am responsible (or maintainmg the backwater prevention device and keeping <br /> it in good workmg order, unless it is installed in the clry right•of-w�Y <br /> � It I sell my property, I will make potential buyers a�vare of the tiackwater prevention deyice and <br /> Ihe need to inspect and maintain it on a regular bas:s. <br /> 4 I am enclosing all of lhe necessary papenvork(use lhe yeilow Rebate Submitlal Checkllst). <br /> Select irom the (ollowing: <br /> � 7he contraclor id ho1ulse and he nslal�Icd de•�ic�e)'and�rerno edaor rerouted them. �o my sewer <br /> Gne (behveen my <br /> i� To my know�edge, my property has no downspoul5 or o�her drainage connected to my se�ver line <br /> (behveen my house and the installed device). <br /> � andf Iherinstalled device)r I ulnderstand Ihat leav ng Ihese coi necUons or�eates e nsk of-0ood'i g <br /> and I accept that risk <br /> � � <br /> �l'� �L{�t�� Date <br /> Signature_ _ <br />