Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> E,, Rebate Application Form <br /> Property Ovmer �Jame I )�� �� �- L���i'i. I <br /> Installation Address: � � � � ����LLt-� T-T� <br /> City: '�l�_�'y � __State: l� Zip �cS�� ) <br /> ��Sailing Address (i(di(lerent) __ <br /> City: EVt'��- State: lil�7� Zip' ��ZC' � _ <br /> Email:�lR� ^ ��' "'O�. C�!"�� Phone: �-{-�f-'j_���—S 1G7-� <br /> � <br /> Total Cost to Install Device ((rom contractorinvoi.e): S_�����_ <br /> I — <br /> Please verify the following: <br /> �� I am the o�:�ner oi the property v+here the backwater prevenlion device v+as installed. <br /> � I worked wilh ihe contractor to determine the location for the back�vater prevention de� :e and <br /> understand that the decision regarding the location o(the device�•�as mine. <br /> �` My contractor instructed me ho�v to aceess, inspecl, and maintain the device. <br /> � I understand that I am responsible for maintaining tne backv�ater prevention device and keeping <br /> it in good �vorkinn �rder, unless il is installed in tiie city ric',n-�.-�aay. <br /> � If I sell my property, I ti•adl make potential buyers aware ol the bachwater preventio�device and <br /> the need to inspect ard maintain it on a regular basis. <br /> �I am endosing all of the necessary papenvork (use ,he yellow Rebale Submiltal Checklist) <br /> Select irom the following: <br /> ❑ The contraclor idenldied downspouts or olher drainage Ilines lhat were connected lo my sewer <br /> line (beriveen my house and the installed device) �nd removed, or rerouted them. <br /> � To my knowiedge, my property haa no downspouts or other drainage connected ro my sewer line <br /> (between my house and the installed device). <br /> ❑ There are do�vnspouts or other drainage lines connected to my sewer line (between my house <br /> and the installed device). I understand that leaving lhese connections creates a risk of flooding <br /> and I acc�pt that risk. <br /> Sicnature l l �A �'�+ �{"1��1� Date_L� <br /> � —� <br />