Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address: � I 2`l I�a-�L•LLC�Z__t�v �= A�L= t= <br />City: i�J�RL J..( State:���__Zip:��aQj=a�� <br />Mailing Address (i(dillerent): <br />City: _ State:_ 2ip: _ <br />Email: Phone: (y15) � q — �, 70S <br />Total Cost to Install Device (from confractor invoice): S_�`i�7� •�" <br />Please verify the following: <br />� am the owner of Ihe property where the backwater prevenlion devicf: was installed. <br />�I worked with the conlractor to delermine the location (or the backwater prevention device and <br />understand that the decision regarding the location of lhe device wa�, mine. <br />',�My contractor instructed me ho�u lo access, inspect, and maintain lhe device. <br />� I understand that I am responsible for maintaining the backwater prevention device and keeping <br />il in good working order, unless it is installed in the city right-oi-way. <br />�f I sell my property, I v�ill make poter;ial buyers aware of lhe backwater prevenlion device and <br />;lie need to inspect and maintain il on a regular basis. <br />�I am enclosing all oi the necessary paperwork (use the yello�v Rebate Submittal Checklist). <br />Select trom the following: <br />❑ The contractor idenli(icd downspouts or other dramage Il�nes that were connected lo my sewer <br />line (between my house and the insta0ed device) and removed, or rerouled them. <br />�o my knowledge, my propeAy has no downspouts or other drainage connected lo my sewer line <br />(bet�veen my house and tlie inslalled device). <br />� There are downspouts or other dreinage lines connected lo my sewer linc (between my house <br />and the instalted device) I understand that leaving ihese connections creates a risk of ilooding <br />and I accept thal risk. <br />Signatare / � Date .2 /� <br />