1331 HOYT AVE 2022-04-19 - Laserfiche WebLink

G`�'�"" Backwater Prevention Device Rebate Program Rebate Application Form -- - -- --- - —M Pr:;�e,R O;:ner Name' _, � __ F' Y �L'.��)s_�'�(_L�`��— - --- Installa?ion Address / 7 �_� �"l� -- --- - - _--_— �� State: ll/ Z 7� City: IN-�^�-'-- __ �._ P�_ I PAailing�ddress {if diNerantJ:__ _ I � City: ___ State ._ Zip:__ Fina�l: -- — Phone: �25,)'Z� -S3'<Q�_ i I '�o?al Cost ;o Inslail Device (Irom confractorinvnice): $ ___— _ i —1 Please verify the tollowing� �_I I am ine o.vne� o`th= property e:here the bacfi�iater prevention device�vas installcd. ��I �vo�ked with lhe contractor lo delermine Ihe localion for the bar,kwater orevenlion device and undersland ihat the de:ision regardiny the locaban ot the device was mine. � tciy contractor instrucled me ho��lo access, inspect. and maintain lhe device � I undursland that I am recponsible for maintaininy Ihe backwaler prevention device and keeping if in good e�orkiny order, unless il is inslalled in the city right-o(-way. j� If I sell my property, I will make potential buyers a�vare of the backwaler prevention devlce and lne necd to inspecl and maintzin it on � re,yular basis. �j I eun e�iclos'nq ,�II of the necessary paperv�ork (use Ihe yellova Re6ate Submdtal Checkhst). � Select from the following: � �� 1 he r.onlraclor idenli(ied do�;�nspouts or other drainage Ilin<as ihal v�ere conner.led lo my sr.e^er I�ne (between my house and Ihe inslalled device)and removed, nr rerouled lhem. � I To my knoivledge, my proprrty has no do�vnspouts or olher dia�nage connected lo my sea�er line I (bet�vr.en my hcuse and�he installed dr.vice). � i ] Theie are dctvnspouls or olhci diainage lines connected to my sewer line (br,tween my house �nr: the mstalled device) I undersiand lhat Ieaving these connections creates a risk of flooding an�t I ar.r,��p;thol nsk . i Signature_ .�.,-•_-�/�,1� _ Datc_3 Z� /S ��