1915 RUCKER AVE 2022-05-12 - Laserfiche WebLink

i ' Backwater Prevention Device Rebate Program �'I �� Rebate Application Form � � --- -- IProperty Owner Name:J=��? ��/ � �1� L(�(Q-G+ � Installation Address: ��// ( �UC�l�-/� �� � � City: i✓=ff��---State:� _Zip: cic�,.ln/ �4ailing Address (it dille2nt) __ _ _ _ i � Cily: Stale: _Zip:_ � I Email:f[[L��[L�J Mcnl. �n rr� Phone: (�/�-1) 1n7/ G �_ C �� II Total Cost to Install Device (from contracforinvoice): 5 �� I� ! Please verify the following: ( (�I am the owner of the proper�y where the backwater prevention device was installed. r � I worked wilh the contraclor to delermine Ihe localion for the backwater prevention device and undersland thal lhe decision regarding lhe localion of lhe device was mine. � My conlractor instructed me how to access,inspecl, and maintain the device. �� ] I undersland thal I am responsible (or maintaining lhe backwaler prevention device and keeping il in good working order, uniess il is installed in the city right-of-way. i ��] If I sell my property, I will make potential buyers aware of the backwater prevantion device and lhe need lo i�specl and maintain it on a regular basis. i ,�� 1 am enclosing all of the necessary papeRvork(use the yellow Rebate Submittal Checklist). i / Select from ihe following: I � The conlraclor identified downspouts or other drainage Ilines thal were conr�cled lo my sewer Ilinc(between my house and the inslalled device)and removed,or rerouted them. � �] To my knowledge, my properly has no downspouts or olher drainage connecled to my sewer line (between my house and the installed device). I ❑ There are downspouls or olher drainage Iines connected lo my sewer line(between my house and !he inslalled device). I understand lhal Ieavin�lhese connections creates a risk of flooding and I accept that risk. �1 /� I ' r- I r ��,�/,�/� Date v2 -�G../S S n�e � � r ;�__� �,� ` ----___ _ .