Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> f;operty Owner Name: 1/n/AGO �~ _�T��/_/�5� - <br /> � <br /> Ir,sta�lation Address: �'� �7 OC�L��'GGLsv� f���. ______ <br /> City: �l��i.P��_ _State: _�/� Zip:�l <br />� ivlailing Address (il diHercnt): _�?����/�A?Y1�'_,�� <br /> City�s�i��� State: �.�_2ip: 9�1� <br /> cmail'�_S-7Gl/2cr�.C=��/��=�'✓GG+��J Phone: � I.�Q.�' 8�a_�/1/d - <br /> Tolal Cost to Install Device (Irom confractor invoiceJ: $���_ <br /> Please verify the following: <br /> �I am the owner of the property where lhe backwaler prevenlion device tvas installed. <br /> / <br /> [� I Nforked wilh the contracicr to determine Ihe localion for the backwater prevenlion device and <br /> understand thal Ihe decisio� regardiny lhe location of the device was mine. <br /> .��v1y contractor instructed m� how to access, inspect, and maintain ihe device. <br /> [�I understand that I am responsible for mainlaining the backwater prevenGon device and keeping <br /> il in good working order, unless it is installcd in lhe city right-oi-way. <br /> �If I sell my property, I will make polenlial huyers aware o(the backwater prevention device and <br /> the need to inspecl and maiNain il on a regular basis. <br /> �� am enclosing all of the necessary paperv�ork (use the yeilow Rebate SubmiUal Checklist). <br /> Sclect from the tollowing: <br /> U The co�lrador idenlihed do��nspouls or other drainage Ilines lhat were connecled lo my sewer <br /> line (helween my hause anc� the installed device)and removed, or rerauted them. - <br /> �j To my knowledye, my property has no downspouts or other drainaye connecled to my sewer line <br /> (hetween my house and Ihe inslalled devir.e). <br /> ❑ There a�e downspouts or ofhcr draina�c lines connecled to rny sewer line (between my house <br /> and the inslalled device). I understand thal leaving Ihese conneclions creales a risk of flooding <br /> and I accepl Ihat risk. <br /> � <br /> Signature �..c.o � Oate��7�-2��`✓� <br />