Laserfiche WebLink
�,�}� Backwater P�evention Device Rebate Program <br />�'��,,,, Rebate Application Form <br />w _ — . <br />�� ' <br />� PropertyOwnerName: 11Jar�N� �`%i'N�e �J���� <br />—� Q�,� <br />! Installation Address: q I D ���Qr "� " — <br />i City: � 12✓<Jul Stale. _w � Zip: I p��% ( <br />Mading Address (if dillerent): <br />Ciry' State: Z�P � <br />�� �� � \ <br />Email C V'tH va d av �Com Phone: (7�Q 9f S'�i��.ZZ <br />Total Cosl to Install Device (from contractor invoice): S 7�`� 9 7`t � <br />Please verify the following: <br />� I am Ihe owner oi the prope ,ry where Ihe backwater prevention device was installed. <br />� I worked wllh the contractor to delermine Ihe location for the backwater prevention device and <br />understand that the decision regarding fhe location of Ihe device was mine.�ec<��r�ed«1 6y se'.'t• <br />�, h1y contractor instruded me how to access, inspect, and maintain the device <br />� I undersland that 1 am resoonsible tor maintaining Ihe backwater prevention device and keeping <br />it in good working order, unless it is inslalled in lhe ciry righl•o(•way. <br />� If I sell my property, I wlli make potential buyers aware of the backwater prevenlion dewce and <br />the need to inspect ar,d maintain it on a regular basis. <br />[�I am enclosing all oF the necessary paperwork (use the yeilow Rebate Submittal Checklist). <br />Select from the following: <br />[] The contraclor identified downsp6�ls or other dramage Ilines that were connected to my sewer <br />I�ne (between my house and the installeo device) and removed, or rerouted them <br />� To my knrnvtedge, my property has no downspouts or other drainage connec'eA to my sewer line <br />�behvee.n my house and ihe installed device). <br />❑ There are downspouts ot olher drainage iines connected to my sewer line (beriveen my house <br />and Ihe mstailed device) I understand that (eaving lhese connections creales a nsk of flooding <br />and I accept that risk <br />Signature afe 7 '�a !� <br />