Laserfiche WebLink
, - - _ _ - - _. _ _ . . ------ <br /> �I <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> I <br /> � <br /> Property Owner Name: —,� R Q(� �^` --�� r <br /> � Installation Address: I E7 D 9 C M a 1'���c ✓��4 � ��� <br /> i <br /> Cily: ,L'�i r�'f'� State: v✓�._Zip: °l 82 0 ! — <br /> Mailing Address (il diHerenQ: P �7• 1J v -,�' 6 l'� -- <br /> City: 1 de�t''4� State: �.J'-. z�P: q8a o 6 — <br /> Emaii: S�_ u fe� <br /> �,� e c ,,,`�q j} ,,� e�_ Phone: (h�� 2Sa � 8'I �'7 _ <br /> 2+{ 8'1 3 � I <br /> Total Cosl to Install Device (from contracfo�invoice): S = I <br /> J <br /> Please verify the following: <br /> [�I am ihe owner of the property where the backwater prevenlion device was installed. <br /> [�I worked with the contractor lo delermine the location for ihe backwater prevPntion device and <br /> understand that the decision regarding the location of lhe device was mine. <br /> � My conlractor instructed me how to access, inspect,and maintain the device. <br /> [� I understand that I am responsibie For maintaining the backw��ler prevention device and keeping <br /> it in good working order,unless it is installed in the ciry right-of-way. <br /> [�If I sell my property, I will make potenti�l buyers aware ot 1hE backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> [.�I am enclosing all of the necessary paperwork(use the yellow F?ebate Submittal Checklisl). <br /> Select from the following: i <br /> [�The conlractor identitied downspouls or other drainage Ilines that were connected to my sewer <br /> line(betwecn my house and the installed device) and removed,or rerouted Ihem. <br /> [] To my knowledge, my prope�ty has no downspouts or other drainage connected to my sewer line ; <br /> (between my house and the instalted devicc). � <br /> � There are downspouts or olher drainage lines connected to my sewer line(belween my house <br /> and the inslalled device). I undersland that leaving these connections creales a risk of flooding <br /> and I accept that risk. i <br /> p�X„�� Date 1 - G - i.f • i <br /> Signature�l � I <br /> I <br /> i <br />