1011 HEWITT AVE 2022-04-19 - Laserfiche WebLink

i ; Backwater Prevention Device Rebate Program � Rebate Application Form , i � � PropeAy Owner Name:�(� I e S z-'��` I Installation Address: I 0 ( � -�� � City:� V�F �a I I State: �J�Zip: °� $ZQ � . Mailing Address (if diHerent): " ' City: Stale: Zip: Email: . Phone: ( ) � Total Cost lo Install Device(lrom contrectorinvoice): $ �� — � , . _ , � Please vedfy the following': ' . • � , � I am the owner oF the property where the backwater preyention device was installed. �worked with lhe contractor ta determine the.location fo�the backwater prevention device and understand that the�decision regarding itie loration of the de"vice was mine. i �My conlraGor instrucled me how to access, inspect, and'maintain the device. i � I understand,that�l;am.responsible fo�maintaining fhe backwaler preventlon device and keeping, , it in good working�ord'er, unless it i's installed iri the ciry righNof-way. � .. . ; � If I sell my propeity, I will make potential bi�yers aware of the backwater prevention device and i ihe need to inspect and maintain it on a regular basis. I • R i � I am enclosing all.of the necessary paperwo�k(use the yellow Re6ate Submittal Checklist). ; Select from the following: i �The contractor identified 'downspouls or olher dCainage ilines Ihat were conn.ebted to my sewer I line'(behveen my house and the inslalled device)and removed, or rerouted lhem. � Ta my knowledge, my property has no downspouts or other drainaae connected to my sewer line � betvreen my house and the installed device). � ❑ There are downspouls or other drainage lines connected to my sewer line (belween my house � and lhe installed device). I undersland that leaving these connections creates a risk of flooding � and I accept that risk. I � I i � � Slgnatu►e b Date � � i � � I ( - -- -- --- -- - ---- -- -- - - - __ _ - - __ ..