804 HOYT AVE 2022-04-19 - Laserfiche WebLink

Backwater Prevention Device Rebate Program Rebate Applica�ion Farm Property Owner Name: �1 v Instaliation Address: -i"Y J J- - -� — �- -- City:-I, __� _State� Vv� Zip: �%�o'-�� Mailing Address (if diHerent): ciry• cmall: State: ZiP: Phone:( ) Total Cost to Install Device (from contrectorinvoice): 5 �' •.� �� Please verlfy the following: � am lhe owner of the property where the backwater prevention device was installed. �I worked with 1he contractor to determine the localion for ihe backwater prevention device and understand ihat the decision regaMing the localion ot the device was mine. � My contraclor inslructed me ho�v to access, inspect, a.id mainlain the device. I understand that I am responsibie for maintaining the backwsler prevention device and keeping it in good working order, unless it is installed in tha city right-of-way. � � If I sell my property, I will make potenliai buyers aware of the backwater prevention device and lhe need to inspect and maintain it an a regular hasis. � I am enclosing all ot the necessary papenvoric (use the yello�v Rebate Submlltat Checklist). Soloct from the following: [] The coniractor identified downspouts or other drainage Ilines that were connected to my se�ver Ilne (belween my house and the installed device) and removed, or rerouted them. � To my knowledge, my pruperty has no downspouts or oiher drainage connected to my sewer line (belween my house and the installed device). r] There are dovmspouts or other drainage lines connected lo my se�ver line (behveen my house and the installed device). I understand lhat leaving these connectlons creales a risk of 9ooding and I accept that risk. / � Date � � ( /' Ii l < �l � Signature � � �� '• ' � �'',, � � � .. 4 � v' _ ,_ ' `+FM �S FM�f f4,:Nr r r . � � �wW��w..�:+.�r.'+rrwww�t�+.vn!i` \� +.,. ` 'cch �tair WN14YL'' a.�� . . �Ylrt{21 t �• b•