Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />t„ Rebate Application Form <br />� <br />Properl,v Ovaner Name� �_ (4 iyl�f ���L �� <�(�. 1 <br />Inslallation Address. J,/ � �- i�>> r �'�. � <br />_/'�— �__ _._ _ �-. <br />• <br />_, _� , <br />c��y _L Jc'�1 � _.--- siai� �-`_'_�{ . z�p ��� ��'' f <br />Mailing Address (il diKerenlJ: <br />City:._ ---- Slale Zj�� <br />EmaiC _._ . _ . .___ _____._ _ ---- Phonc ( ) <br />_...: _._.._ <br />.� ,. <br />Tolal Cost to Install Device {Irorn r.onUacror invoice): S__,_� i'f �, E�> F' <br />Please verify the following: <br />� am the ormer of the proprrty whcre Uie bar.kwater prevenlion devicc �,v�s instalhzd. <br />[j I worked with the contraclor I�: , ; mine the lor.aiion (or the backw;ilr.r pmvenlicm devicr, and <br />undersland that the decision reg�i,iing lhe locatinn of fhe device was mine <br />(�f My contrar,tor instructed me how to access, inspec�, and mainlain Ihr. device. <br />I`�I understand ihat I am responsible for mainlaining Ihr. backwa�er pir.v�mlicm drtvii:u :md kecping <br />it in gnod working orcler, uniess it is installed in Ihe cify right-vf-w,�y <br />(� I( I sell my property, i will make polen(ial buyers aware of Ihe backwaler prr.veMlon dcvir.e and <br />the need to inspect and main�ain i� on a regular hasis. <br />�'1 am enclosing all of the nr cessary papen,ork (use Ihe yellow RebAI(? SUI)II11I��11 (;�I(!CI(IISI� <br />Sclect from the following: <br />[� The contraclor identified downspouls or ofher dminage Iline; Ihal wcrc coiin,�r,lr.d lo my scwer <br />line (be(ween my house and thc inslalled tlrvice) and removed, or reioufed Ihem <br />�� To my knovdedge, irY Property has no dovmspuuls or olher drair��ryc r.onnar.led in my sewer line <br />(bctv;een ,ny house and Ihe inslralled dewce) � <br />� � There are doe✓nspouls or olher draui�ige lines connected to nry sewe� lin�r (I,r.lwe,�n nry huuse <br />and Uie insfalled device) I intders(and �hal leaving ihese r.onncr.liuic; crc:des ;i iisk of Ilonduig <br />and I »ccep( (hat risk <br />Si�naturc � ( Dafe V'� L✓ – �� <br />..A��-- --�-� . _. <br />