3006 16TH ST 2022-05-18 - Laserfiche WebLink

� rr Backwater Prevention Device Rebate Program Rebate Application Forrr� Property Owner Name: l_�!^ �-',� � � 'i'�w' � ^ "� ' ' - `' `" Installation Address� / ��'b � � �1 G q� Ciry: %l-ZN'-C � State: �� 1 zip: I C�1� Mailing Address (if diNerentf. �`"� � � ) � 1 � ��' ' " � City: ��-vz��v..�, State: �� Zip: ��,,^ •- Emait2� �^ � ?✓Aw. �� ,.�t � C,v`� Phone: (7.u'•) ,� y '- �i�Z[}'� Tolal Cost to Install Device (from contractor invoice): S pl ase verify the following: [� I am the owner of the properly ��here the backwater preventior device was installed. [� I worked with Ihe conlractor to determine the location for the backwater prevenlion device an� understand that the decision regarding the location oi the device was mine. 1� N e► My contractor inslructed me how to access, inspect, and maintain Ihe device. I understar � lhat I am responsible for mainlaining the baclavater prevention device and keeping it in good working order, unless it is instailed in the city right-of-vray. If I sell my property, I will make potentiai buyers aware of ihe back�vater prevenlion device anti the need to inspect and maintain il on a regular basis. I am enclosing all of the necessary paperwork (use the yellow Rebale Submitlal Checkiist). Select from the following: ❑ The conlractor identified downspouts or olher drainage Ilines that were connected to my sewer line (be6veen my house and the installed device) and removed, or rerouted them. � To my k�owledge, my property has no downspouts or other drainage connecled to my sewer line (be[we�n my house and the instailed device). ❑ Tt ere are downspouts or other drainage lines connected to my sewer line (behveen my house aud the installed device). 1 understand lhat leaving these conneclions creates a risk of Ilooding and I accept lhat risk. /� � Date � � � � � Signature I