Laserfiche WebLink
4 Backwater Prevention Device Rebate Program <br />Wrr Rebate Application Form <br />Property Owner Name: P-bat�i� V PrNI Sm+ <br />Installation Address: 1-1I Z 24j .- , n <br />City: (5�-elze* --State: tA2� A • _ Zip: <br />Mailing Address (if different): <br />City. <br />State: <br />Email: Phone: ( <br />Total Cost to Install Device (from contractor invoice): $ <br />Please verify the following: <br />I 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 />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 I 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 />�i 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 ether drainage [lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />9 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 />❑ 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 tkat risk. <br />Signature Vu-+' ` Date S-) 3 `�S <br />