1222 RUCKER AVE 2022-05-12 - Laserfiche WebLink

I i , Backwater Prevention Device Rebate Program ! � Rebate Application Form � Property O�vner Name:�E�,Q +"[ VEct�l S j 2 W InstallationAddress: � 22��l.lc.:��.�__�t1G_•. _ _ - City:�C Q i� I i State: V�_� __Zip:�� ?,�� i Mailing Address (i/diNerenf): `� A M G= _ __ _ _ __ � City: State: Zip: __ I Emai�:��(L TCP o,GCM(;�S i , t.1 ET Phone:(`�2�"� �L5 c4 ' �3 1 I ITotal Cost lo Instail Device(from contractorinvoiceJ: $ a`I C7L�� � Please veriy the following: � �am the owner of the property where the back�vater prevention device was installed. ' [�I worked with the conl�actor to determine the location for lhe backwaler prevention device and Iunderstand that the decision regarding the location o�the device was mine. i [t� My contractor instructed me how to access, insped,and maintain the device. �I understand Ihat I am responsible formaintaining the backwater prevention device and keeping it in good working order, unless it is installed in the cityright-oi-way. I �If I sell my property, I will make potential buyers aware of the backwater prevenlion device and � the need to inspect and maintain it on a regular basis. , (�I am enclosing all of lhe necessary papenvork(use the yellow Rebale Submitlal Checklist). iSelect from the foilowing: ❑ The contreclor identified downspouls or other drainage Ilines thal were connected lo my sewer ' Ilnc(behveen my house and lhe inslalled devicel and removed,or rerouled them. i iQ�To my knowledge, my property has no downspouts or other drainage connected to my sewer Ilne I (belween my house and the instalied device). � ❑ There are downspouts or other drainage lines connected lo my sewer line(behveen my house i a�d the inslalled device). I understand thal Ieaving these connections creates a risk of flooding and I accepl that risk. I i I Z S � Signature Date 2" � � � � I i I