Laserfiche WebLink
01/14/2010 18:29 TEL 4253578857 U 001 <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: -€ <br /> Installation Address: <br /> City: _e w _State: ` Zip: C>1 n o 3 <br /> Mailing Address(if different): <br /> City: State: Zip:_ <br /> Email: �``n'1&A/13P Phone: ( ) <br /> Total Cost to install Device (from contractor Invoice):$ 72.J.4 4 <br /> Please verify the following: <br /> a/(am the owner of the property where the backwater prevention device was installed. <br /> [,worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> a].4,1y contractor instructed me how to access, Inspect, and maintain the device. <br /> 1114understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> B41 sell my property, i will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> WI;m enclosing all of the necessar <br /> y paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> Q The contractor identified downspouts or other drainage!lines that were connected to my sewer <br /> line etween my house and the installed device)and removed, or rerouted them. <br /> o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device), <br /> 0 There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). i understand that leaving these connections creates a risk of flooding <br /> and i accept that risk. <br /> Signature � �— ,— ate If- 9 5- /YgE©g <br /> i <br /> PUBLIC WORKS <br />