Laserfiche WebLink
� Backwater Prevention Device Rebate P�ogram <br /> Rebate Application Form <br /> Property Owner N�me: Fe/�J Q e�?_ <br /> InstallationAddress: /�G� lZ�k�� <br /> City: (iVere�"�' State: In/'�' Zip: ��La/ _ <br /> Mailing Address(i(differenf): � -- -- <br /> City: State: Z�P <br /> Email: Phone: (�/7j) ?S� - ��� <br /> Total Cost to Instali Device (from contrector invoiceJ: 5� C��� <br /> Please verify the following: <br /> i <br /> � � I am the owner of the property where the backwater prevention device was installed. <br /> � I worked wilh the conlractor lo determine the location for t::.: backwater prevenlion device and <br /> undersland lhat the decision regarding lhe localion of the device was mine. <br /> My contraclor inslructed me how lo access, inspecl, and maintain lhe device. <br /> I understand lhat I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> �J If I sell my property, I will make potential buyers aware o(the backwater prevention device and <br /> r Ihe need to ins�ecl and mainlain il on a regular basis. <br /> �I am enclosing all of the necessary paperwork(use the yellav Rebate Submittal ChecklisQ. <br /> Select from the following: <br /> � The wntractor identified downspouts or other drainage Ilines thal were connected lo my sewer <br /> line(between my house and the instailed device) and removed,or rerouted lhem. <br /> ❑ To my knowledge, my property has no downspouls or olher drainage connecled to my sewer line <br /> (betvreen my house and lhe installed device). <br /> `{,[� There are downspouts or olher drainage lines connecled to my sewer line(betwecn my house <br /> T` and ihe installed device). I undersland thal leavinc� these conneclions creales a risk o(Oooding <br /> and I accept lhal risk. <br /> � <br /> � � <br /> Signamre Date � — �y' �S <br />