Laserfiche WebLink
, � - . . , � <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> ------ �----------- ---- <br /> Property Owner Name: ��-F— �T 1 1�/5(� f <br /> Install tion Address: I �O 7 � � � � � �� <br /> y —• � P�lL' d+�l <br /> Cit : i7a ri.tQ State: Zi <br /> Mailing Address(if diKerentJ: <br /> City:_ State: _Zip: _ <br /> Email:. ,Phone: ( ) <br /> Total Cost to Install Device (frorn�onfraclor invoiceJ: $ �3�� � ^ _ <br /> Please verify the following: - <br /> �am ihe owner of tfie propeAy where the backwaler prevention device was installed. <br /> [� I worked with Ihe contractor lo determine the location for the backwaler prevenlion device and <br /> undersland ihat the decision regarding the location of the device was mine. <br /> [�My contraclor insUucted me how lo access, inspec�, and mainlain ihe device <br /> [�I understand that I am re'sponsib'a for maintaining the backwaler prevenlion device and keeping <br /> it in good working order, unless it is :�stalled in ihe city right-of-v.�ay. <br /> [�j If I sell my properly, I will make potential buyers aware of ihe backwater prevenlion device and <br /> Ihe need to inspect and maintain it on a regular basis. . <br /> �v'I am enclosing all of the necessary paperwork (use Ihe yetiow Rebale Submitlal Checklist). <br /> Select from the following: <br /> ❑ The contraclor identifieo downspouts or nlher drainaye Ilines Ihat vaeir, connected lo my sevaer <br /> line(belween my house and the installed device)and remnvr.d, or rr.routed Ihem. <br /> �To my knowledge, my property has no downspouls or other drainage conneclyd !o my sewer line <br /> (hetween my house and ihe inslalled device). <br /> ❑ There are downspouts or othcr drainaye lines connected to my ::ewr.r line (belween my house � <br /> and the installed devic�). I understand that leaving Ihese connr.dions r.real�s a ri;k of(looding <br /> and I accepl that risk: <br /> Signafurc_ r Datc ��L Z�/f 7 <br /> 1 <br />