Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropeRy O�vner Name�N�s �"��� �� <br />Installalion Address: �� (� '�� rti lU!� . - ��� � ✓� � ��'� <br />c�ry: '�v�V1,�� sta : (Nt4- _zip: i�'a�`z._ <br />Mailing Address (i( dilterenlJ: � �U � 6 %� � "" �� _ <br />City: �U��''�-�'i� State: �,Uu1- Zip: �' � � � <br />�� �. <br />Email:�D�Jl��ow.�l�✓U�S . Cac� _ phone M21j y� _ 2060 <br />Total Cost to Install Device ((rom contractor invoice): S��• `�' �'"� <br />Please verify the following: <br />�} I am the owner of the property where fhe backwater prevention device was installed. <br />_` <br />�I worked with the contrector lo determine lhe location for the 6ackwater prevention device and <br />understand that the decision regarding the location of lhe device v�as mine. <br />�My contractor instrucled me how to access, inspecl, and mainlain lhe device. <br />� 1 understand that I an responsible irr maintaining the backwater prevenlion device and keeping <br />it in �ond vrorking ord=r, unless il is inslalled in the cily right-of-way. <br />�I( I sell my property, I will make po�entiai buyers aware of Ihe back�vater prevenlion device and <br />the need to inspect and maintain it on a regular basis. <br />yy� i am enclosing all of the necessary paperwork (use the yello�v Re�ale Submiltal ChechGst). <br />'-\ <br />Select from the following: <br />❑ The contractor identified duwnspouls or olher drainage llines thal were connecled lo my sewer <br />line (belween my house and lhe inslalled device) and removed, or rerouted them. <br />o my knotivledge, my property has no downspouts oi other drai,�ay� connecled to my sewer linc <br />(between my house and the installeu device). <br />❑ Tnere are downspouts or olher drainage lines connected lo my sewer line (between my house -. <br />anJ Ihe installed device) I understand thal leaving these connrctions creates a risk of (loodirg <br />and I accept that risk. <br />,; � ������ <br />Signafure_/ � '�� Date <br />