Laserfiche WebLink
Backwater Prevention Device R�bate Program � <br /> Rebate Application Form <br /> � - <br /> IProperty O�r,ner Name: v T �_�o L D i�(13 n! <br /> i <br /> � Ins;allation Address: �3�' 13 a3 ; o yT fF _ u E � <br /> I ciry: �v��r� State: Wi� zip: G/ g Z U I � <br /> IfvlailingAddress (ifdi/fer�:nO:�pX �.�GZ– I <br /> Cily: 1`1U K I L T��✓ State: W� 7_ip: ��S � <br /> , 1 I I <br /> � �mail: ti D6 �d1.ta/J(t+� aLG � , LCirn Phone: (y�>'f s�`' = 7Z7`�_ � <br /> i —�_� <br /> Total Cost to Install Device(fiom contractorinvcice): $_ � i <br /> Please verify the following: i <br /> (�' I am the ovmer of the prope�iy where the backwater prevention device was installed. � <br /> �i�vorked with the contraclor to delern;ne the location for the backwater prevention device and � <br /> understand that the decision ragarding the localion of the device vras mine. � <br /> [�Iti1y conlractor instructed me how to access, inspect, and maintain the device. � <br /> � <br /> �y)' I undersland tha! I am responsible for maintaining the 6ackwater prevenli ;n device and keeping ' <br /> t <br /> il in good c;orking order, unless it is inslalled in the city right-of-way. j <br /> f <br /> ti If I sell my oroperty, I will make potenlial buyers aware o`the backwaler prevention device and ! <br /> the need to inspect and maintain it en a reyular basis. � <br /> i <br /> �I am enclosing all of the necessary papenvork(use the yelio�v Rebate Submittal Ch��cklist). ! <br /> Select from Uie following: � <br /> i <br /> r <br /> ❑ The contractor identified downspouts or other Crainage Ilines that were connected to my sewer <br /> line (between my house and the instailed device) and removed, or rerouted them. <br /> ❑ �fo my kno�vledge, my proper�y h2s no downspouts or other drainage connected to my sewer line � <br /> (belwcen my house and the installed device) , <br /> [},�There are dotvnspouts or other dnin�ge lines connected to my se�ver line(between my house � <br /> and the ins(alled device), I undersfand thal leaving these connsr.tions r.reales a risk of�looding <br /> and I ar,r,�pt thal risk. <br /> Signature �'�� Date (O `� � v 7 <br /> v <br />