Laserfiche WebLink
Backwater Preventiun Device Rebate Program <br /> Rebate Application Form <br /> Property0evnerName: f� G� � G�O� �,�C�l7��P (�� �SO��) <br /> Installation Address: � �{ � � G/YxHC1 N-t/Eri��+�. <br /> City: ��� State: _ t�__Zip:_ `�R2.�) I <br /> Moiling Address(i(dil(erenQ: �N� (T S �'�[�c/E <br /> City: State: Zip:. <br /> Email:��r�}c,��.�u���(n,vi Phone: (yl�'� E'�-2- 7 74�_ <br /> Total Cost to Install Device (from contractorinvoicej: $ LS'f��J."� <br /> Please verify the following: <br /> �I am the owner of the prop=rty where the back�vater prevention device was installed. <br /> �I worked with the contractor to determine the looalion for the backwater prevention device and <br /> understand that the decision regarding the location of Ihe Jevice was mine. <br /> �My contractor instructed me how to access, inspect, and maintain the device. <br /> �I understand that I am responsible for maintaining ihe backwater prevention device and keeping <br /> it in good working order, unless it is inslailed in the city right-of-way. <br /> �j If I sell my property, I will make potential buyers aware of the backwater prevenfion device and <br /> the need to inspect and mainlain it on a regular basis. <br /> �f I am enclosing all of ihe necessary papenvork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> ❑ The contractor identified downspouts or other drainage Ilines thal wcre connected to my sewer <br /> ine(behveen my house and the installed device) and removed, or rerouted them. <br /> To my knowledge, my properly has no downspouls or other drainage connected to my sewer line <br /> (bchveen my house and ihe installed device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and the installed device). I understand ihat leaving these connections creates a risk of flooding <br /> and i accept that risk. - <br /> Signature 7�/i l �� Dafe i�I Y��r <br />