2301 STATE ST 2022-05-16 - Laserfiche WebLink

%,�}� Backwater Prevention Device Rebate Program Y��'� Rebate Application Form ' Property Owner Name: _,�]rc "�'`� l 5 s l%<. �-, �O ��f '-_ � Installation Address: % 7 n[ S%� Y= S i— � Ciry: ��' �, J�` State: V✓� Zip:� ;i Z r%/ Mailing Address (if di/lerent): Cily: State: Email: Phone: ( ) �4�>�' �}Y 0 Total Cosl to Inslail Device (lrum contracfor invoice): 5�� 3� _ Please verify the following: jj� I am the owner of the property where the backwater prevention device was inslalled. 'r� (�jj I worked wilh the conlredor lo detertnine the localion for the backwater prevention device and �` understand thal the decision regarding the location ot the device was mine. � My contraCor instrucled me how to access, inspect, and mai�tain the device. �J I understand lhat I am responsible for malntaining the backwater prevention device and keeping il i� good working order, unless il is inslalled in the city right-of-way. [� II I setl my property,i will make polential buyers aware of ihe backwater prevendon device and the need lo inspect and maintain il on a regular basis. , ❑ I am enclosing all of lhr. necessary paperwork (use Ihe yellow Rebate Submittal Checklist). Select firorn the (ollowing: (�%J The conlractor identified downspouls or olher drainage Ilines that were conncdeA to my sewer line (belwecn my house and Ihe installed device) and7emoved, or rerouted lhem. [] To my knowledge, myproperty has no downspouts or other drdinage connecled to my sewer line .. (between my house and the inslalled device). �There are downspouts or other drainage lines connecled to my sewer line (belween my house and the installed device). I under3tand Ihatleaving these connedions creates a risk oi flooding , and I accRpt ihat risk. ;;,: i � ,//, a, � L ( /� J SignaWre ,� ;� �� / Date " ~ � / � � � �• , `;, .