Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> E„ Rebate Application Form <br /> Property Owner Name: ✓J GU <br /> Installalion Address:�� <br /> City: �l � P/�Y�� State: f,()l� Zip: C���n � <br /> Mailing Address(il different): �II2� <br /> City: State: Z�P� <br /> Email:�(yJ �14r/�,�� /U.qIYIC�fC� GD/Yl Phone: (L/�tX v�/D/ �7 <br /> Tolal Cost lo Inslall Device (lrorn con;ractorinvoice): 5 <br /> �Yd'y. 30 <br /> Please verify the following: <br /> �I am the owner.of the property where the backwater prevention device was installed. <br /> ��vorked with Ihe contraclor to determine lhe localion for the backwater prevention device and <br /> understand that the decision regarding the localion of the device was mine. <br /> [�My contraclor instructed me how to access, inspect, and maintain the device. <br /> �understand lhat I am responsibie.for maintaining the backwater prevention device and keeping <br /> it in good working order, unless il is installed in the cily right-of-�vay. <br /> �I sell my property, I will make potential buyers aware of the backwater prevenfion device and <br /> the need lo inspect and maintain it on a regular basis. <br /> �am enclosing all of lhe necessary paperwork(use lhe yellow Rebale Submiltal Checklist). <br /> Select from the following: <br /> �The contractor identi(ied downspouts or other drainage Ilines thal were connected to my sewer <br /> line(belween my house and the installed device)and removed, or rerouted lhem. <br /> ❑ To my knowiedge, my property has no downspouls or other drainage connected to my sewer line <br /> (behveen my house and the installed device). <br /> ❑ There are downspouts or othe� drainage lines connected to my�ewer line(between my house <br /> and the installed device). I understand that leaving these connections creates a risk o(flooding <br /> and I accept thal risk. <br /> Signature �Yr(� T('jl,t.1J� Date L� l � <br />