Laserfiche WebLink
---- -- - - -- - - `_` � --- -_ _— _. .._ . .__-- -- -- -- <br />Backwater Prevention aevice Rebate Program <br />^i!7_"" Rebate Application Farm <br />Properly Owner Name: l�l IrP�SC-� S� / VI�-, <br />Installation Address: Z$�� �t"Oi�Ct� � ` <br />ciry: ��Qh�._ sta�e: �.�1,�____ zip: �`d Zd I <br />Mailing Address (if diHerentJ: <br />�i�y: State: _ Lip: <br />Email: �UCPsc(5c�2(�,�2� hokmci�Q,. Cnm Phone: (�,5) 2,3$- 263� <br />Total Cost to Inslall Device (from contraciorinvoice): $ <br />Please verify the following: <br />�� m the owner of ihe properly where lhe backwater prevenlion device was installed. <br />worked with the conlractor lo determine the location for the backwater prevention device and <br />understand thal lhe decision regarding the location of the device was mine. <br />�My coniractor instructed me how to access, inspecl, and mainlain ihe device. <br />�understand lhat I am responsible for mainlaining the backwater prevention device, and keeping <br />d m good working order, unless it is installed in the city right-of-way. <br />I/J If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />� the need to inspecl and maintain it on a regular hasis. <br />� am enclosing all of the necessary papenvork (use the yellow Rebafe Submiltal Checklist). <br />Select from the following: <br />n The conlraclor idenlified downspouls or o�hcr drainage Ilines that were cnnnected to my sewer <br />line (hetween my house and lhe installed device) and removed, or rerouted them. <br />� my knowledga, my property has no downspouts or olher drainage connected to my seever line <br />(between my house and the installed device). <br />U There are downspouls or other drainage lines con�ecled to my sev�er line (between my house <br />and lhe installed device). I underslandlhal Ieaving !hese connections creales a risk of flooding <br />and I accept that risk. <br />Signature �"'"'—��� /�� __ Datc `_`7_` ` / � J _ <br />T" <br />