1714 WETMORE AVE 2022-05-17 - Laserfiche WebLink

I , � � �� Backwater Prevention Device Rebate Program �w��„ Rebate Application Form .�--- PropeRy Owner Name: �i � o � �� Inslallalion Address: 1� � �� .1�2�tv� O.-L � — Cily: �r,�,-��- State: `-L�� Zip; � � �� � Mailing Address(il dillerenl): � �( �SZC� 1 City:_'�J[�(P�� Slate: �..��-' 2ip: UZ S- 6nail: Phone: ( j Z.�13 -�S�� � � Total Cosl to Install Device(Irom confractor invoice):$ � Piease verify the following: �am fhe owner of lhe property where the backwater prevention device was installed. � � I worked wilh the coniractor to delermine the iocation for ihe backwater prevenlion device and i understand that the decision regarding the locafion of Ihe device was mine. i � My contractor instructed me how to access, inspect, and maintain lhe device. � I understand that 1 am responsible for maintaining lhe backwater prevention device and keeping it in good working order, unless it is installed in the city righl-of-way. �{ If I sell my prope�ty, I will make potential buyers aware of the backwater prevention device and i, the need to inspecl and maintain il on a regular basis. j f�l I am enebsing all of Ihe nocossary paperwork(use the yellow Rebate Submiltal Checklist). -r Select from the Follawing: Q� The coniraclor idenlified downspouls or other drainage Ilines lhal were connecled to my sewer , line(belween my house and Ihe inslalled device)and removed, or rerouted lhem. � � To my knowiedge, my property has no downspouts or othcr drainage connected lo my sewer line � (belween my house and Ihe inslalled device). I � There are downspouls or other drainage lines cornieded lo my sewer line(between my house and the Inslalled device). I undersWnd that leavina these connecllons creales a risk of floodinA and I accepl Ihat risk. I Signature � � Date Z/ZZI� � I