Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />i <br />InstallationAddress: zs32 20Gk� -�� �� <br />City: �� State: /.f/f�. Zip: fBLa/ -- <br />Mailing Address (il differenf): <br />City: Stale: _ Zip: <br />Email: C!i•�G�i�� �t���y�,y� Phone:��) x�12-�O��.J <br />Total Cost to Inst211 Devir.e (trom conlracfor invoice): S i��fQ%• � — <br />Please verify the following: <br />�am the owner of the property where lhe backwater prevention deaice.was installed. <br />�I worked with the contractor to determine the location for the backwater prevention device and <br />undersland thal the deci=ion regarding (he location of the device was mine. <br />(�My contraclor instrucled �ne how toaccess, inspecl, and maintain the device. <br />[�I understand that:l•am responsible for. maintaining the 6ackwater prevention device and kee,�ing <br />it in good working order, unless it is installed in the city right-of-way. <br />�f I sell my property, I will make polential buyers awa�e of the backwater pievention device and <br />the need tb insper.t and maintain it r,n a regular ba'sis. <br />�I am enclosing all uf lhe necessary paperv+ork (use the yello�v Rebate Suhmittal Checklisl). <br />Select from the tollowing: <br />❑ The contractor identified doemspouls or other drainnc�e �iines thal were connected to my sewer <br />line (betwaen my house and the installed device) and reraved, or rerouled lhem. <br />�To my knowledge, my prooerly has no downspouts ur olher drainage connected lo my sewer line <br />(between my house and lhe Installed devicc). <br />� ✓ <br />,� There are downspoufs or other drainage lines connected to my sewer line (belween my house <br />and the inslelled devicc). t undorstand lhat leaving Uiese connections creatcs a risk ot 0ooding <br />and I accept lhat ris�c. <br />i Signature Gu-w`"�� "d' v"��Date /�J �� ���� <br />