707 HOYT AVE 2022-04-29 - Laserfiche WebLink

� Backwater Prevention Device Rebate Program Re'eate Application Form Properly Owner Nam�.: _ I ()�`� ;�y Instaltation Address: � aty: rC'�I-PEP��--- sca : Mailing Address (if diNerent): _ _ City: Stat,�: Email: _ ,IV/1 Zip;�l�C�� Fhone: ( Total Cost to Install Device (liom contractorinvoice): $ a��Efl Please verify the follo.wing: � I am the owner of,the property where the backtvater prevention deVice was installed. � I worked with the contractor fo determine the location (or the backwafer prevention device and understand that the decision regarding the location of fhe device was mine. i71 My contractor insiructed me how to a�cess, inspect, and maintain the device. /�� �] I'understanii lhat I am responsible (o� maintaining the bacn�Nater prevention de4ice andkceping / it in good working order, unless it is installed In the city rig�d-c -way. ' �[� If l'sell my property, I v�ill make polential buyers aware of the backwater prevention device nnd i lhe need to inspect and maintain it on a regular basis. � I.am enclosing all of the,necessary paper4ork (use the yellow Rebate Submittal Checklistl. ; Select from the (oi;�wing• [�� Thc conlractor identified downspou�s or other drainage f�nos that were connecled to my sewer Cne'(between iny house and lhe installed device) and remc:�d, or rerouted them. i [Y� To my knowledge, my properly has no do�vnspcuts or other drainage wnnecled to my sewer line (bet�veen my house and ihe installed device). ❑ There are downspoufs or other drainage lines conneded to my sewer line (helween my house and the installed duvic�). I understand that leaving lhese connections creates a risk of flooding and I accept that risk. Slgnatu a' ' � Date � ��'/ 5 ' '�n . r.-h, +*R.-�lC. .: vw �W - r ,°r a �' �� eS:.M.. .,r ,� -:' .. m'wns �. . �0� �. 3%yI Jt ^� .�Yw�p.� ... m � Mw.��i v4„ v� � � +"' •. > +s�+ y� t .iw�Yw�'�` e �,,,« .::a..�we pL: �. w . � � .. .w „ ��r�.+wr L�iMs�r� 'Y ��__.��" �;a�a___.T _� _