2621 ROCKEFELLER AVE 2022-05-12 - Laserfiche WebLink

'A✓, , Backwater Prevention Device Reb�te Program Rebate Application Form Property Owner Name: Jo� � �oL $�1aWrt� Installation ; ddress: �ll City: F�� _ State: bl�� Zip: r��Q� Mailing Address (if diHerent): �g3� �i� � �v1t • /�/� City: l.a � r�it S f /`�rk Slate: W/t z�p: `�8"(s s Email: r��Ve� q w1al �. C �n'l Phone: �c,$j 91[ -67 /�7 Total Cost to Insiail Device (/rom confractor invoice): 5 � 2`t 9 6. 3 I Olr, tn r {'�'�o�x'?+� ct�h'¢r Please verify lhe tollowing: � � 71"e^+k- II d i„�,,,, vT34?3 %'�' dl am the owner of the property where the backv+ater prevenhon dewce was insta e. �� y[YI worked with the contractor to determine the location for the backv�aler prevention device and ° l��/.� understand Ihat the decision regarding the location of the device was mine. �� tity coniractor inslructed me how to access, inspect, and maintain the device. �I undersland that I am respon:.ible for maintaining lhe backwater prevention devi�e and keeping it in good working order, unless it is installed in the r.ity right-of-way. []� If I sell my property, I will make potential buyers aware of the baclnvater prevention device and the need to inspect and maintain it on a regular basis. (y��l am enclosing ail of the necessary paperwork (use the yellow Rebate Submittal Checklist). Select from the tollowing: i The conlraclor identified downspouls or other drainage Ilines thal were conn^cled to my sewer � line (behveen my house and ihe installed device) and removed, or rerouted them. � ❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line � (between my house and the installed device). ❑ There are downspouts or other drainage lines connected to my sewer line (benveen my house and lhe installed device). I understand that leaving these connections creates a usk of (looding and I accept that risk. Slgnature �'�%� �/�✓{" Date //-6'/S