Laserfiche WebLink
�� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address: �D`�—� ��2—� �vr <br />City: �(�12=i— Slate: .� Zip: a�'�� <br />Mailing Address (il dilferenf): <br />City: <br />State: <br />Email: __ _Phone:�� 1�1--1�v�� <br />Total Cost to Install Device (from caitractor invoice): $ �iQ� �� <br />Please verify lhe followi�g: <br />�am the owner of the property where the backwater prevention device �vas installed. <br />[�worked wilh the contraclor lo determine the location for the backwaler prevenlion device and <br />undersland that the decision regarding the localion of lhe device was mine. <br />� contractor inslructed me how to access, inspect, and maintain the device. <br />[�understand that I am responsibie for maintaining the backwaler prevention device and keeping <br />it in good working order, unless it is installed in the city righ4of-way. <br />f I sell my property, I will make potenlial buyers a�vare of the backwater prevention device and <br />llie need to inspect and maintain it on a regular basis. <br />m enclosiny all of lhc necessary papenvork (use lhe yellow Rebale Submillal Checklist). <br />elect from the following: <br />�he coNraclor idenliFied downsnouts or other drainage Ilines lhat were connecled to my sewer <br />line (between my house and the installr.d device) and removed, or rerouled them. <br />�] To my knawledge, my property has no downspouls or olher drainaye connected to my sewer line <br />(between my hnuse and the installed devir,e). <br />(] There are downspouls or other drainaye lines connected to my sewPr line (belween my house <br />and Ihe inslalled device). I understand lhat Ieaving Ihese connections cre�tes a risk of flooding <br />and I accopt that risk. <br />Signatu ���� Date � z3 � S <br />