Laserfiche WebLink
'_"'_." __ ""___�____" _� _"�i '.. _ ' __. . ..____'_ ". <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: � �^�' I �1 � l� b Bv'� <br />Insfallation Address: 0 /�- t��_��� __. <br />City: ��sGti State:�__Zip: ���-D/ <br />Mailing Address (if diNerent): <br />City: <br />State: <br />Email: N���i�`{'S 3z= %�G,V*�t �.('c�,-.-. Phone: ('Y�o2�� —1)JS�� <br />Total Cost.to Install Device (from cunfractor invoice): $ a.�-s T• � � <br />Please verify the following: <br />✓I am the otivner of tne property where the backwaler prevention device was installed. <br />p'�I worked with the coMractor lo delermine the location for lhe backwater prevenlion device and <br />understand lhat lhe decisior, regarding the location of the device was mine. <br />�(v1y contraclor instructed me hove to access, inspect, and maintain the device. <br />�I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in lhe city right-o(-way. <br />It I sell my property, I will make polenlial huyers aware of the backwater prevention device and <br />the need to inspecl and maintain it on a regular basis. <br />�I am Enciosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />n 1'he contraclor identified downspouts or olher drainage Ilines thaf vdere connected to my sewer <br />[�ne (between my house and ihe installed device) and removed, or rerouled lhem. <br />To my knowledge, my prope�ty has no downspouts or other drainage connecled to my sewer line <br />(bebveen my house and lhe installed devicel <br />❑ There are do�vnspouls or other drainage lines connected to my seuver line (behveen my house <br />ard lhe installed devir.e). I understand thal leaving these �onnections creates a risk of flooding <br />and I accept that risk. <br />Signature / � ��""�Date _ T ' � � — �'� <br />