Laserfiche WebLink
�^%6�4"" Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> _ - ------ -- - - --- — I <br /> � � c��' Sf/'r�,✓ "�,� <br /> iProperty O:mer Name. ��i _ __�__ __ <br /> Installation Address: r� � �. �j�f�'T � ✓� I <br /> � Ciry� �� ��1�'�'"1�"�' Slale� w� Zip: t�� � _ � <br /> � , <br /> <<�ailing Address (if di((erent) ; <br /> City: -_---- — Stale' ---2ip � <br /> �1 � _ I <br /> Email: CUC���"�� S�i^l_�or�l^� y.;9,W ��o i' _ Phone (��.� J-,S:t - �YS � <br /> Total Cosl to Install Devico (!rom confraclor mvoiccJ. $_��_��._g�__ <br /> Please verify the following: <br /> �I am the ovmer of the property�vhere Ihe backvialer preveNion device was installed. <br /> �i�I c�orked �+ith the conlraclor to delermine the location for�he backwater prevenlion device a� � <br /> unde�stand lhat Ihe decision regarding the location ol lhe device was mme. <br /> ;L N1y contrector ins!ructed me ho�v to accesc, inspect, and maintain lhe device. <br /> [�I understand that I am responsible lor maintaining the backwatrr prevenhon devir,e and keepin� <br /> il in good�vorking order, unless it is mstalled in lhe city right-oLway. <br /> �7 If I sell my property, I w.ill make polential buyers aware ol!he backwa�er prevention device an� <br /> the nced to inspect and maintain it on a regular basis <br /> j�; I am enclosing aIl of the necessary papenvork(use Ihe ye�low R�bate Submittal Checkhsq. <br /> Sclect trom the following: <br /> j�J The coNraclor identilied do�•mspouls or olher dramaye Ilines Ihal were connectea to my sewer <br /> line (betvreen my housr.and the installed devir.e)and removed,or rerouted lhem. I <br /> (] To my knov�ledge, my property has no doernspouls or other drainage connecled to my sewer line <br /> (bct�vicen my house and lhc fnstalled dce�ice). <br /> � I here are downspouts or other drainage lines connoded to my srwcr hne (ben•:ccn my ho��se <br /> and thr, inslal�ed dev�ce) I unders�and that Ieaving lhesc connedions creates a nsk o((looding <br /> and I accept �hat ns'�. <br /> �I <br /> �; , ;) <br /> Signature_��,,c,(,_'^-� ��j U��t,:r-" Date _= -�.`.��,� <br />