2813 PINE ST 2022-05-04 - Laserfiche WebLink

. Backwater Prevention Device Rebate Program Rebate Application Form Property Owner Name: `�TPuen �v�I NfMYr — I InstallationAddress: o? �CS� 3 /"/N� 5� ` City: �V e/'e� _ State:�_Zip: �O �� � Mailing Address (Ndifferent): � S �� S o��e �/ ; City: /9 Lt7 U�Lt State:�Zip: -/ l� Q D / � Email: S fPUPaII�.,�rr3�9''i� oo�Cc�''�Phone: (�.ZSj �/oy-2cil�2 iTotal Cost to Install Device (irom contractor invoice):$��j ��a � � - � Please verify the followiag: I i �am the owner of the property where the backwater prevenfion device was installed. [� I worked with the contractor to determine the location tor the backwater prevention device and I understand that the decision regard�ng the location of the device was mine. �[VS y contractor instructed me how to access, inspect,and mainlain the device. understand that I am responsible(or maintaining the backwater prevention device and keeping it in good working order, unless it is installed in the city right-of-way. [7f If I sell my property, I will make potential buyers aware oi lhe backwater prevenUon device and the need to insped and maintain it on a regular basis. I (y'�I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). � Select trom the tollowing: ! The contreclor identi(ied downspouts or other drainage Ilines lhat were connected to my sewer � ne(between my house and the installed device) and removed, or rerouted them. T my knowledge, my property has no downspouts or other drainage connected ta my sewer line , ehveen my house and the instalied device). � ❑ There are downspouts or olher drainage lines connecled to my sewer line(belween my house _ and the installed device). I understand that leaving these connections creates a risk of flooding � and I accept that�sk. � { � : ISignature �y Date l/ a7 / � f i I --=- -- - - - - --- -- -- - --- - - - --- - --_ .�