1421 LOMBARD AVE 2022-04-29 - Laserfiche WebLink

- --�- -- - - - - - - _ . -i Backwater Preventioi� Device Rebate Program Q, Rebate Application Form Property Owner Name: L av`✓' y J�Z1�'SOu Installation Address:��Z,_[ _�e� l04 r � City: ��l2µm'� State: _— /� ZiP:_��j'z D� Maiiing Address (i(di/ferent): �oL�q�i� �`r'� _ City:_ /�q N Y 5�'�— Slate: _�a=_Zip:_��.Z 7 D Email: /pYPY � N�'/t�,��P+•1tir�e . cv� _ Phone: ��/�.�_359-/Sg`� � Total Cost to Install Device lrom contraclor invoice : $ � �' ( ) �2-_ c-: i Pleas�: verify the following: I am the owner of the property where the backwater prevention device was instalied. �Yf worked with the con,rsctor lo delermine the location for the backwater prevention device and �nderstand tiiat the decision regarding the localion of the device was nine. ,�'tviy cont�actor instru�ted me how to access, inspect, and maintain lhe device. � understand !h�t I am responsible for maintaining the backwater prevention device and keeping it in good working order, unless it is installed in the city righl-of-�vay. ,� If I ;ell my prope�,y. I will make potential buyers aware of the backwaler prevention device and Ihe need to inspect and mamt:�in i[on a re9ular basis. �I am �nclosing all of lhc necessary paperwork (use the yellow Rebate Submiltal Checklist). Select from the following: �J"The contractor identified downspouts or other drainage Ilmes thal v:erc connected to my sewer line (between my house and the installed device) and removed, or rerouted them. �To my know!edge, my property has no downspouls or other drainage connecled to my sewer line (Cetween my hause and the inslailed device). i �'7here are dow!ispouts or other drainage lines connected to my sewer line (between my house and the installed device). I unde;stand ihat leaving these connections creates a risk of ilooding and I accepl that risk Signature---`�2�'�'^'`.t�� Date �` 7 '/j