Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />�� <br />Property Owner Name• ���� j " � <br />. • � � � • � �J��f►T111'i/I <br />� � • <br />�;���r!��1 ' ��� <br />Mailing Address (il dilferenQ: '"'�'— 6��_ i�!h�J;�� <br />City: ��� Slate: � 2ip:�d � <br />Email: <br />Total Cost to�lnstall Device (from contractorinvoice): 5 <br />Phone: ( <br />Please verlf the following: <br />am t-ovmer of the property where Ihe back�vater prevention device was mstalled. <br />worked with the contraclor lo determine Ihe localion for Ihe backwaler prevention device and <br />understand lhal lhe decision rec�arding the location o( lhe device was mine. <br />y coniractor instructed me how to access, inspect, and maint:�in the device. <br />underslond thal I am responsible for rr �`ntaining Ihe backw�ter prevention device and keeping <br />it in good working �rder, unless it is installed in lhe city righl-of-way. <br />I sell my propeAy, I will make potential buyers aware ol the back�vater prevention device and <br />lhe ne d lo inspect and maintain it on a regular basis. <br />(�, am enclosing all o( ihe ner.essar; papervrork (use the yellow Rehate Submiltal Checklist). <br />Selecl from the following: <br />i7 The contractor idr,nlif:ed downspouls or other drainac7e Ilines that were connected lo my sewer <br />linc (b een my house and Ihe installed device) and removed, or rerouted them. • <br />� o my knovAedge, my property has no downspouts or other drainage connected to my sewer line <br />(belween my house and the inslalled device). <br />[J There are downspouts or olher drainage lines connecled to my sewer line (betv+een my house <br />and lhe installed device). I understand lhal leaviny lhese conneclions creales a risk of Oooding <br />andlacceplthatnsk. <br />� , � `� <br />� <br />Signafure / ' Dafe �� <br />