Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br />Reb�te Application Form <br />Property Owner Name: Cha�iQS�C4�"�°e'� L�"<<�7zr� <br />/� 0 <br />Inst211atinnAddress: c%��U ��ona�rJ' 7JR <br />Ci1y L—`�/c= 2 � T�" State: W i'� <br />tJlailing Addr'ss (if differenQ: <br />City: <br />Email: <br />Slate' <br />Total Cest to Inslall Device ((rom contractorinvoice): S <br />Please verify the following: <br />C/�.�0 � <br />Phone:( ) <br />c, o <br />� i <br />f� I am the owner of the property where ihe backeva�er prevention device c�as ins�alled. <br />>� <br />i, , I wor!ced c�ith the contractor to determine the location for Ihe backv+ater prevenlion device and <br />understand that the decision regard�ng Ihe localion o( the device was mine. <br />[j My contractor instrucled me ho�v to access, inspect, and maintain Ihe device. <br />[]�I understand thal I am responsible (or mainlaining the backwaler prevention device and keeping <br />il in good �vorking order, unless il is installed in the c�;y right-of-way. <br />� I( I sell my properly, I will make polential buyers aware of the Uackaaater prevention device and <br />the need to inspect and mainlain it on a regular basis. <br />��I am enclosiny all of Ihe necessary papenvork (use the yellow Rehate Subm:tlal Checklisl) <br />Select Iront the tollowiny: <br />(] The coNructor ident�6ed downspouls or olher drainaae Ilines that were connected to my sewer <br />line (6elween my house and ihe installed device) and removed, or rerouted ihem. <br />��To my knowledge, my property has no downspouls or clher drainage connected to my sewer I�ne <br />(beriveen my house an 1 ihe installed device). <br />❑ There are do�mspouls or other drainage lines connected lo my sewer !ine (behveen my house <br />and Ihe installed devir,e) I undersland lhaf leaving these connections aeates a risk of flonding <br />and I accepl Ihat risk <br />Signalure �ij%�� t .f� � Datc �— C! —� � <br />