Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> ; Rebate Application Form <br /> � <br /> IIProperty Ovoner Name:�ji�c� l ,�1c-�IZl <br /> InslallationAddress: 1���- W���e-- t�'�^'�- <br /> City:�__Q.Jti� S�ate: 1„�Yt Zip:��'1 Z?J 1 <br /> Mailing Address (if diHerenQ: _ _ ___—_ <br /> I City: State: Zip: <br /> I Emaii: �!��n��ta�-1w�� 1n1��.�.i' CAv�^ Phone: (�/ZS)�"�() -Ud'., ( <br /> ; Total Cost to Install Device(lrom contrac(orinvoice): $ 2f,s'o�.� <br /> I <br /> � <br /> i — - <br /> i <br /> I Please verify the following: <br /> �m the owner of the property where the backwater prevention device was instailed. <br /> � I worked with the contracbr lo delermine Ihe location tor the backwater prevenlion device and <br /> I <br /> understand lhat the decision regarding ihe location of the device was mine. <br /> j ❑ My contractor ins�rucled me h�::to access,inspect,and mainlain the device. <br /> [�I understand Ihat I am responsible tor maintaining the backwater prevention device and keeping <br /> I il in good working order, unless it is instalied in the city riyht-of-way. <br /> i <br /> ' Q�If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> � the need to inspect and maintain it on a regular basis. <br /> , [..f'I am enclosing all of lhe necessary papenvork(use lhe yellow Rebale 5ubmittal Checkiisl). <br /> I Select from the following: <br /> ❑ The contractor identified downspouls or other drainage Ilines lhal were connected to my sewer <br /> � line (belween my house and lhe installed device) and removed,or rerouled lhem. <br /> � [�To my knowledge, my property has no downspouts or other drainage conner.ted to my sewer Ifne <br /> (between my house and the installed device). <br /> � [] There are downspouts or other drainage lines connecled lo rny sewer line(belween my house <br /> i and the inslalled device). I understand that leaving ihese conneclions creales a risk of(looding <br /> and i accept thal risk. <br /> I <br /> i � <br /> I Signature _Date � - �J'�UI S <br /> I <br />