2201 RUCKER AVE 2022-05-12 - Laserfiche WebLink

I �� Backwater Prevention Device Rebate Program �w��.., Rebate Application Form �..�,, Property Owner Name: �'rV\ "'� � � lJ7J�� Installalion Address: ,�� 1��1 7�V`�J City: �–C��.11�—State: VV/� Zip: 1.,,'ULS1� 1 I ��Qailing Address(iI dif/erent): � ! City: Slate: Zip: � � '1 i Email:��"O�,A, Y1"Il� (Ef��'1C7�1"Y�l��n1 Phone�� I I Tolal Cosl lo Install Device(from contracrorinvoice): $ �� I ; Plea verify the following: I �m the o�vner of the property where the backwater prevention device was instalied. � I worked with the contractor to determine the location for the backwater prevention device and � undersland ihal the decision regarding the location of lhe device was mine. My conlractur instrucled me how to access, inspect, and mainlain the device. j � I understand Ihat I am responsible for maintaining lhe backwater prevention device and eping i --� it in.good�vorking order, unless it is inslalled in the cily righl•o_f-w_ay. r�l.�+o� � ��e(:�� u. rYGu�i�ilrl i f I sell my property, I will make potential buyers aware of Ihe backwaler preventi n device and the need lo inspect and maintain it on a regular basis. �am enclosing all o(the necessary paperwork(use lhe yellow Rebale Submittal Cher.klist). I i Select from the following: ❑ Th oontraclor identitied downspouts or olher drain�ge Ilines Ihat were connecled to my sewer li e (between my house and the inslalled device)and removed,or rerouled Ihem. To my kno�vledge, my properly has no downspouts or other drainage connecled to my sewer Iine (belween my house and the installed device). ❑ There are downspouts or other drainage lines connected to my sewer line(between m/house and Ihe installed device). I understand that leaving these conneclions creates a risk of tlooding and I accepl that risk. Signature \ '��Le�O/ 1 Date l/�J I�V � I � 1