1509 RUCKER AVE 2022-05-12 - Laserfiche WebLink

� � I � Backwater Prevention Device Rebate Program � Rebate Application Form ! i � Property Owner Name: ��; n bec-t � �r'I ��U i ^ I InstallationAddress (5Q 4G er /ttrP ��iP � city: E uP rP.f�- � State:_ Il�l f4 ZiP'_ ��.20 � ' I Mailing Address (iidifle�enl): i I City: State: Zip: EmaiC KiH6erIU C f 1 �Iu � ��a�o� C�N1 Phone: (�,�_�2 — 7S .6 ' � Total Cost to Install Device (Iiom contractorinvoice): 5 2� �1 �i,S� , � � _ ; Please verify the following: ` � 1 am the o�vner of the property where the backwater prevention device was installed. � I � I worked with the coMractor to determine the localion for the backwater prevention dewce and ` understand ihat the decision regarding the location o(the device was mine. [� My contractor instructed me how to access, inspecl, and maintain lhe device. � [�(! I understand 1ha1 I am responsibie for maintaining the backwafer prevention device and keeping I it in good working order, unless it is installed in the city righf-of-way. � � � If I sell my property, I will make potential buyers a�vare of ihe backwater prevention device and , the need to inspect and mainiain it on a regular basis. � I [�J I am enclosing all o(lhe necessary paperwork (use Ihe yellow Rebate Submittal Checkllst). ; Select from the following; � ❑ The contractor identified downspouts or other drainage Ilines Ihat a�ere connected �o my sewer line(behveen my house and the installed devico) and removed, or rerouted them. � � To m knowled e, m I Y g y property has no downspouls or ofher drainage connected to my sewer line (6eriveen my house and ihe insfalled device). ❑ There aro downspouts or olher drainage lines connected to my sewer line (between my house � and the installed device). I understand fhat leaving these conneclions creates a risk o(ilooding ' and I accept ihat risk. � i i / 1 Signature y( Date_p��,Zp��5 ! i � i !