Laserfiche WebLink
4 Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: 44A I-i- 6c 11P A60 ¢, '(DU016 180 0 1—flY <br />Installation Address: "I i <br />City::Cvjm - Slate: W A Zip: — I <br />Mailing Address (if different): 2, 0,�" D 14 It I <br />City: W P(L'PK State: AVA Zip: _C:Lw <br />Email: A- IkNC�O'JIIR e CIA t IDD &)N1 Phone: (Dtp <br />Total Cost to Install Device (from contractor fnvofce): $ <br />Please verity the following: <br />[4 1 am the owner of the property where the backwater prevention device was installed <br />[� I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />[✓ My contractor instructed me how to access, inspect, and maintain the device. <br />Q I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />If 1 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 />[Jf I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />LI There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />signature �u Date <br />i <br />