Laserfiche WebLink
Backwater �revention aevice Rebate Program <br /> Rebate Application Form <br /> r <br /> Property Owner Name:_J,�.�J�I/��."�l/��' <br /> � Q1n <br /> Installation Address: /ll b� ��(� � <br /> � City:�j/� S�ate: W E'�' Zip: Y ►"�.� -- <br /> Mailing Address (ifdilfe�ent): � C � 7 ����� ,J T ���. <br /> I -{-� , / (� <br /> I City: 1�"P� ! ' _ Stdte: �/(Ij_Zip: 7 �Ld� <br /> Email: Phone:� ��a��- C~�� <br /> 30 <br /> Total Cost to Install Device((rom conlracforinvoic�j:$ Z���' �– <br /> Please verify the following: <br /> �1 am fhe ovmer o.`the property where the backwater prevention devic�was (nstalled. ! <br /> �vorked with the conUactor to determine the location for the bacVa�ater prevenfion device and I <br /> undersland that ihe decision regarding the loca6on of the device was mine. <br /> [�,VR�y contractor InsWcted me how to access,Inspect, and malntain the device. <br /> �nderstand thal I am responsible for maintaining the back�vater preven�ion device and keeping <br /> it in good working order, unless it is installed in the cl�y right-of-way. <br /> ' • f I sell my property, I wiil make potential buyers a�vare of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> [! I am enclo>ing all of fhe necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> [�`fhe contractor identified downspouts or othe� drainage Ilines thal�vere connected lo my sewer <br /> lino(behvoen my hause and the instaifed da:vice)and removed, or rerouled them. <br /> To my kno�viedge, my property has no downspouls or other drainage connected to my sewer line <br /> II (between my house and the installed device). <br /> ❑ There are downspouts or other drafnage Iines connected to my sewer line(behveen my house <br /> and the installed device). I understand Uiat leaving these connectlons creates a risk of Oooding <br /> � and I accepl that risk. <br /> I Signature � ' ' Dafe — � ��S <br /> I <br /> � <br /> t <br />