1420 RUCKER AVE 2022-05-12 - Laserfiche WebLink

�--- — - � � Backwater Prevention Device Rebate Program Rebate Application Form Property Owner Name: I�L.4�J�_�_��/<__�_.�G�- r'� LVY�_ Installation Address: I�Z� j��,�[,k p.✓ �✓-�. City:�l/(�✓P t'f— State: In r` Zip: �7 8 2� � Mailing Address(i!different): I � City: State: Zip:--_- [maii: `a h/G�-}�@�Gi J .('srn °hone:(�{2�Z5z -40 5� i Total Cost to Install Device((rom contracfor invoice):3 Z'�4� � i I Please verify the following: '� I am the owner of ihe property where the backwaler prevention device was inslalled. (1(] I worked with the contractor to determine the Iocation for the backwaler prevention device and / ` understand that the decision regarding lhe location of the device was mine. I0 My conlraclor instructed me how to access, inspect, and maintain the device. I �) I understand that I am responsible for maintaining the backwater prevention device and keeping ', i;in goo��vorking order, unless it is installed in lhe city nght-of-way. � If I sell my property, I will make potenlial buyers aware oF the backwater prevenlion device and ; � the need lo inspect and maintain it on a regular basis. , �] I am enclosing all of lhe necessary paperwork(use the yellow Rebate Submi�lal Checklist). � i Select from the following: � ' ❑ The contractor identified downspouts or other drainagc Ilines that were connected to my sewer � line(belwecn my house and thc installed device)and removed,or rerouted them. [� To my knowledge, my proparty has no downspouls or other drainage connected to my sewer line j (belween my house and lhe installed device). I ❑ There are downspo�,ds or other drainage lines connected to my sewer line(between my house and the installed device). I undersland ihat leavinc� lhese connections creates a risk of flooding and I accept ihat risk. Signature�'- /�7�/�^ Date �Z/ ZZ�� � i i i I I I � �