Laserfiche WebLink
Backwater Preventicn Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: I� l 1�-Y1 a�X �' O�t�i e�r-� <br />Installalion Address: l , �� �%��'�/ ��'Y'� <br />City: �� State: � Zip' /p �/ <br />Maiting Address (if di(ferent): __� �� /� ��' KY� <br />City: wv'�W _ State:!'v�Zip: /6 �/ <br />Email: �0.1V����P�� A� • �A�'Y1Ph�e!����� � � <br />Tolal Cost lo Inst II Device (lrom contractorinvoiceJ: $ o( �I� l-'�<l' <br />Please verify the follawing: <br />p� I am the owner of the property where ihe backwater prevention device was instalied. <br />� ., <br />li�( I worked witf� Ihe contractor to determine the location for the backwaler prevention device and <br />jr undersland thal lhe decision regarding lhe localion ot lhe device was mine. <br />� My contractor instructed me how to access, inspect, and maintain the device. <br />�'( I understand that I am responsible for maintaining the backwater prevention device a;:d keeping <br />r it in good working order, unless il is installed in lhe city right-of-way. <br />� If I sell my property, I will make potenlial buyers aware oi lhe backwater prevention device and <br />the need to inspecl and maintain it on a regular basis. <br />� I arn enclosing all o( lhe necessary paperwork (use Ihe yellow Rebale Submiltal ChecklisQ. <br />Select from the following: <br />� The conlraclor idenlilied downspouls or other drainage Ilines that v+ere connected to my sewer <br />line (between my housc anA the installed device) and removed, or rerouted lhem. <br />rj Tb my knowledge, my propeAy has no dov+nspnuts or other drainage connected to my sewer line <br />(belween my house and lhe inslalied device). <br />❑ There are downspouts or olher drainage lines connected to my sewer line (belween my huuse <br />and Ihe inslal!ed device). I understand lhat leaving these conneclions creales a risk of flooding <br />and I accept Ihat risk. <br />��,� ����. G -ZS-/� <br />Signature oa�e <br />