1932 ROCKEFELLER AVE 2022-05-11 - Laserfiche WebLink

Backwater P�even►ion Device Rebate Program Rebate Application Form Property Owner Name: �_ bl.a i n r ^ Installation Address:__�� U�.��tc� ��C� TF � C • City: �.�� State:�Zip: �2 (�� Mailing Address(il diffe�ent): i i City: State:_ Zip:_ � I tS� Cs C �� [�(1�� i�Phone: (��j �0 Z. 0� Email: I Total Cost to Install Device (Irom cor;iactor invoice): 5 _.. _ i � Please verify the following: � � am the owner of the property wher2 lhe backwater prevention device was installed. � i � �worked wilh the contractor to determine ihe location for the backwater prevention device and � understand that the decision regarding the location of the device�vas mine. � �contractor instructed me how to access,inspect, and maintain the device. I ' �1 nu derstand that 1 am responsible for maintaining the backwater prevenlion device and keeping it in gooJ working order, unless it is installed in the city right-of-way. I sell my property, I will make poteNial buyers a�vare of!he backwaterprevention device and - , the need to inspecl and maintain it on a regular basis. ❑ I am endosing all of lhe nece�sary paperwork (use Ihe yellow Re6ate Submittal Checklist). ( � Select from the following: � [�}�he contraclor identified downspouts or olher drainagc Ilines th�l were ronnected to my sewer � line(between my house and lhe installed device)and removed, or rerouled lt�em. ' � ��i o my knowledge, my property has no doe•mspouts or other drainage connected to my sewer line � (between my house and ihe inslalled device). ' i ❑ There are downspouts or olher drainage lines r,onnecled to my sewer line(between my house � and the inslalled device). I understand Ihat leaving ihese conneclions creales a risk of flooding � and I accept that risk. II Q / Signature �� c-v�s"� Date r �S � �