Laserfiche WebLink
OOLBackwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: -J F .J opp-r I-)r _-_ - --- <br />Installation Address: Z 5 1 <br />City: ii Lf P- ) I State: <br />Mailing Address (if different). <br />City: <br />Email: <br />_ Slate. <br />Total Cost to Install Device (from contractor invoice): $ <br />Zip:---- — -- — <br />Phone: ( <br />Please verify the following: <br />l am the owner of the property where the backwater prevention device was installed. <br />[j I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />e7 My contractor instructed me how to access, inspect, and maintain the device. <br />C3 1 understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />0 It I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />Q'I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />[vrl n my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the 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 that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />i <br />Signature --_ -� _ Date _101--L <br />