2202 ROCKEFELLER AVE 2022-05-11 - Laserfiche WebLink

�ackwater Prevention Device Rebate Program Rebate Application Form Property Owner Name: � P�o�� 6G1�� h"qn I �t�'�+ Ya-�- r�V c) 5 D l�( � Inslallation Address: 22�2 �4�.K�T P�l�e'� A�l.. � �.} `-' ! I City: �V�� I _State: �'V� Zip:��2� � + i Mailing Address(if diKerent): _._ _ � Cily: _ State: __ Zip: � Email: Phone: (�Z5) 2 S�I " �S �� I i — i r�� , �, Tolal Cosr to Install Device (from confracfor invoica;: S__"G'9'`i+:-b-0 8 � �� I Please verify the following: i � I am the owner of the property where the back vater pre�cntion device�vas in;talled. ; �v] I worked with the contractor to delermine the IocaG�n ior Ih^ backwater prevention device and j understand that Ihe decision regarding �he location of th. �ievice was mine. ; �v My contractor instructed me how to access, inspect, and maintain the device. � � �] I undersland thal I am responsible for maintaining ihe backwater prevenlion device and keeping I it in good working order, unless it is installed in the city right-o(-way. � ! � If I sell my property, I will make potential buyers aware of the backwater prevention device and , , the need to inspect and maintain it on a regular basis. � i i �v] I am enclosing all �!the necessary papenvork (use lhe yellow Rebale Submittal ChecklisQ. i I Select from the following: � � ❑ The contractor identified downspouts or olher drainage Ilines that were connecled to my sewer ' ' line(between my house and the installed device}and removed, or rerouted them. � �G] To my knowledge, my property has no downspouts or other drainage connected to my sewer line (between my house and Ihe installed device). 1 i � � �\�p(� There are downspouts or olher drainage lines connected to my sewer line(between my house � ` and lhe installed device). I understand ihat leaving these connections creates a risk of(looding ! and I accept lhal risk. � � 9 � - � LI Signature Ma►�� Ld� Date �2 1�' � 1