1909 17TH ST 2022-05-18 - Laserfiche WebLink

Backwater Prevention Device Rebate Program E�, Rebate Application Form Properly Owner Name: j'�P�-�-,�nP i'i� un !� ��5'1�� ibin-,a n n._ ctka b�Ur.,onc1 L'en�si.re5 LLC� Ir.slallation Address: 90 ,_7;� h St _ Cit� : I /�J p re�i- _ State: U) A Zip: � 8�o2Qf �4aiiing Address (i( differertJ: � ��_�i �G% %4� c��Q'�Cl� J Cily:�� State� j�(�� Zip:�,�,3 Emeil: �p�n r.a.e.0 iin� ��c1z� Phone: (425� �1�L2.4 fn FS �� k�; s�n� Tolal Cost to Install Device ((rom confractor invoicef S �>5'UU __ Please verify the following: ❑ I am the owner of the property where the backtivater prevention devir,e was installed. ❑ I worked with the cont�actor to determine the location for the 6ack�vater prevention device and understand that the decision regarding Ihe localion of lhe device was mine. ❑ My contractor instrucled me how to access, inspect, and mainlain lhe device. ❑ I unders�and that I� m responsible for mainlaining the backwater prevention device and keeping it in good working order, unless it is installed in the cily right-of-way. L� If I sell my property, I will make potential buyers aware of ihe backwater pre��cnlion device and the need to inspect and mainiain it on a regular basis. ❑ I am enclosing all of lhe necessary papenvork (use the yelloea Rebate Submittal Checklist). Select irom the following: [] The contractor identified downspouts or olher drainage Ilines that were connected lo my sewer line (befween my house and the installed device) and removed, or rerouted them. ❑ To my knowledge, my property has no downspouts or other drainage connected �o my sewer line (belween my house and the installed device). ❑ There are downspouts or other drainage lines connected lo my sewer line (behveen my house and the inslalled device). i undersland that leaving these connections creales a risk of flooding and I accept that risk. Signature _ � !3 rt. % Date �l - ZZ - I � V