Laserfiche WebLink
Backwater Prevention Device Rebate Prc•gram <br />Q, F�ebate Ap�lication Form <br />Property Owner Name: '- bq-� _ /�vi <br />InslallationAddress: 333"Z �"T� T �� _ _ <br />City: � vElZ�-- State: �✓,!� . Zip:_ Q�ZC) � ---- <br />MailingAddress(ifdiHerentJ: l�• D. �� S`J�� _ <br />c�ty: L=1/�11� state: G�n z�p:_ q'�z�.�' <br />9 � <br />Email: �c!.fC ff/ � S yC� C�ortitC /��, �2T Phone: (4'z� qZ 3- `%3 — <br />Total Cost to Instali Device (lrorn -.onfracbrinvoice) $��1-1 �-� <br />Please verify the following: <br />� I am lhe ovrner o( the property e;here lhe back�vater prevention device was installed. <br />6c] I worked with the contraclor to delermine the location for !he backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />[�. M� conlrzclor ��slrucled me how to access, inspeci, and maintain the device. <br />0 I understand that I am responsible for maintaining the backwater prevention device and keeping <br />il in g000 .�orking order, unless it is installed in the city right-o(-way. <br />� If I sell my praperty, I�vill make polenlial buyers aware of lhe backwater preventior. device and <br />the need lo inspect and maintain it on a regular basis. <br />[� I am enclosing all of lhe necessary papenvork (use the yello�v Rebate SubmiCal Checklisll. <br />Select from the following: <br />`� The conlraclor idenlified downs�outs or olher d. ainage Ilines ihat ���ere, conner.ted to my sewer <br />line (between my house and the installed devic:) and remuved, or rerouted them. <br />� To my knowledge, my property has no downspouts or nther drainagc connectsd to rny sewer line <br />(between my house and Ihe installed device). <br />❑ There are downspouts or other drainage lines cennected to my sewer line (belween my housc <br />and the installed device) I understand that lea�ing ihese conneclions creates a risk of flooding <br />and I accep! �hat risk. <br />;i � <br />i J � i- <br />Signafur '^G � ���a�-�'�� o ZOi � <br />J <br />