Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> f" ' '� , 1 <br /> Property Owner Name:��u�S � �z�ie LJLLYI�o rTv� <br /> InstallationAddress: ���� �l.�ki� <br /> City: f�Vrifz,-t"t' State:�_Zip: �c�o2� ( <br /> Mailing Address(if diHerenf): <br /> City: State' Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (Irom contractorinvoice): 5 ��J• 86 <br /> Please verify the fallowing: <br /> I am the owner oi the property where the backwater prevenlion device was installed. <br /> �orked wilh the contractor to determine the location for the backwater prevention device and <br /> understar�'�hal lhe decision rec�arding lhe Iocation of the device was mine. <br /> �M conlractor insiruc�ed me how to access, inspect, and maintain ihe device. <br /> I understand lhat I am responsible for maintaining lhe backwater prevention device and keeping <br /> il in good working order, unless it is installed in the city right-o(-way. <br /> �f 1 sell my property, I�vill make potential 6uyers aware oi the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> �am enclosing all uf the necessary papenvork (use the yellow Rebate Submitlal Checklisq. <br /> Select from the following: <br /> ❑ The conhaclor identified downspouts or other drainage Ilines lhal were connected to my sevrer <br /> line(belween my house and lhe ^islalled device)and removed, or rerouted them. <br /> �To my knowledge, my property has no downspouts or other drainage connecled lo my sewer line <br /> (between rny house and the inslalled device). <br /> ❑ There a;e downspouts or other drainage lines connected lo my se�ver line(between my house <br /> and the inslalled devico). I undersland thaf leaving Ihese connecdons creates a risk of flooding <br /> and 1 accept !,iat risk. <br /> Signature � � �t�LJC� Dafc �� �n" ls <br />