Laserfiche WebLink
Backwater Prevention Device Rebate (�rogram <br />Rebate Application Form <br />Pro�erty Owner Name: �LcL� �TSP/-' <br />in;tallalionAddress: Z/LZ `i?�(�OLf�,�LC. �1�� <br />c�ry� Eri�—�E'�7" <br />h4ailing Address (ir diNerent)� <br />City: <br />'mail: <br />Stale: :'�'�- Zip: �� L �� <br />State� <br />� Total Cost to Instaii Device (/rom contrac�orinvoice)-5 <br />Please verify the f�llowing: <br />'Lip <br />�none: ( <br />�am the o�vnar of lhe property where the backwater prevention device �vas installed. <br />/ <br />� I v�orked with the �ontractor to determine the location for the backwater prevention device and <br />understand th��i the decision regarding the location of the device c�as,mine. <br />� My conlractor instruUed me ho�v to access, inspect, and mainlain the device. <br />�undarstand that I am responsible for maintaining the hackwater pr?ventior� device and keeping <br />it in go�d working order, unless it is installed in the city right-ob�vay. <br />�F I sell my property, I wili make potential buyers aware of the backwater prevention device and <br />the need to inspect and mainlain il on a regular bnsis. <br />[j�am enclosing all of the necessary papenvork (use the yeliow Rebale Submittal Checklist). <br />Select irom the following: <br />rJ The conlracror idenh6ed downspouls or o�her drainage Ilines lhat were connected to my sewer <br />line (beriveen my house and the inslalled device) and removed, or rerouted them. <br />(►� my knowledye, my property has no downspou!s or olher drainage connected lo m� sewer line <br />(between my house and Uie installed devicc). <br />❑ There are downspouts or other drainac�e lines connected to my se�ver line (benveen my house <br />and Ihe inslalled device). 1 undersland Ih�t leaviny these connections creates a risk of Oooding <br />and I accept that risk. <br />Slgnature f�`� �� Date _ 7 L� �J�- <br />