Laserfiche WebLink
�' <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />PropeAy Owne�r Name: ��Q����]RR� 7 <br />InstellationAddress: 3�.%� (�Vt�.�i �R'C1J� <br />Clry: �yK'R _ State• ��� 2ip _a�S3G� <br />Ma'ling Addreee (Il tllherenQ ��OS �t.' ��A� �f�' 't1�IC <br />Ciry:_�.CCC� Stoto:�� Zlp: ��ZU3 <br />Emall CIJ�� CCG�L�1 � ��1�M1•(X�M' Phone�LS) ZS �0�� <br />\ ��- <br />Total Coet to Inatall Devlce (liom conl�ecfo� Involce): E a��� S <br />Pls��� v�rlfy ths following: <br />� I am the owner ot Ihe property where Ihe backwater prevention device wae installed. <br />Ip{ I worked with t�e canlractor lo Jetermine Ihe location (or the backwater prevention devlee and <br />'� underslend Ihat ihe Oeaslon reparding the lotatlon o1 tne deviee was mino. / <br />� My conlractor I�etruded ma how to access, Inspect, end meinlein the devlca.l�`� �'�`A'��' J <br />� I understand thet I em recponslble for meinteininp the Dackwatei Drevenllon Oevica end keopinp <br />II in �ood wo�klr,g order, �nlees II le Inetallad In lhe clty rl9ht•ol•wey. <br />�] II I scU my proparty, I will maAe polantiel buyors ewere of tha hackwater prevrntion device and <br />the nead to In�pect and mefmain it on � repulv b�ob. <br />❑ I am enclosinp all ol Ihe necessary paperwork (uae the yellow Rebate Submitlal Checkliet). <br />6elecl irom tho following: <br />�] Tho conlraclor fdeMiOed downepou(e or othar drainago Ilines tbet wero connected lo my eewor <br />Ilne (between my house and t�e innlallad devlce) anA removed, or rcrouted them. <br />�o my knowledAe, my property has no tlownnpoute or olher d�einugo connecled Io my eewer Ilne <br />(6ntwnen my houeo rnd Ihe Inalnlled devlce). <br />❑ Therc are downspouls or olher dralnape linee connecled lo my sewar linc (botwean my houee <br />entl Ihe ineletlad devlco). I underelend thet leaving thaee cannecllone createe e rlek of IlooEing <br />end I accepl thal dsk. <br />Slpn�tun \FY+I Oaro V� t �Z \1 <br />