Laserfiche WebLink
_._ __ _ . ..�_____ . � _ . ._ �_ .�.,�-Y' �t <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />ProperlyO��nerName: ��\V�Yti l�Ot'S�.'t�h <br />Installation Address: �� � \��* �� e-- <br />Ciry: ��e-Y ' Slale: L..) R Zip: 'Q��O, <br />Mailing Addr�ss (ildiflerent): <br />Cily: _— _ _ State: c�p: _ <br />� c� j(� -% Phone: � <br />Finail: ���r���]C� C�uY�CO._— �� — lii��.�`�—[?� <br />Total Cost to Install Device ((rom contractor invoiceJ: � o'� �f'� L� 8 g _ <br />Please verify tiie following: <br />I am the owner of the property �vhere the backv+ater prevenlion device was installed. <br />I worked with the contractor lo determine the localion for the backwater prevention device ai;d <br />undersland lhat lhe decision regarding lhe location of the device was mine. <br />4y conlractor inslrucled me ho�v to access, insper.t, and maintain the device. <br />understand thal I am responsible for maintaining the backwaler prevention device and keeFing <br />it in good working order, unless it is installed in the city righl-of-way. <br />( I sell my property, ' �vill make potential buyers aware of the backwater prevention device and <br />the need to inspec! nnd maintain it on a regular basis. <br />am enclosing all of the necessary papenvork (use the yelbw Rebate Submillal Checklis[). <br />Select from the following: <br />�j ihe contractor idenlified downspouts or other dra;nage Ilines lhal were connected to my se�ver <br />�ine (I�ete�een my house and the installed device) and removed, or rerouled them. <br />To my kno�vledg�, my properiy has no downspouts or other drainage connecled lo my sewer line <br />(between my house and lhe installed device). <br />❑ There are downspouts or other drainage lines connected lo my s.^.wer line (between my house <br />and the installed device). I undersland that leaving these connections creales a risk of flooding <br />and I accepl thal risk. <br />Signafure��✓^�� Date � �7� � � <br />