Laserfiche WebLink
, <br /> . ! <br /> { <br /> ; <br /> Backwater Prevention Device Rebate Program i <br /> Rebate Qpplication Form I <br /> . ; <br /> � <br /> Property Owner Name: e/J��f � �����T'�/� j <br /> L i <br /> Installalion Address: � ��� `� � � ��/'� <br /> Ciry: /`+�r�V,� O, ' State: C�/ . , Zio:_Q�`�Z�� � <br /> I <br /> Mailing Address (ii diKerent): i <br /> i <br /> Ciry: State' Zip: 1 <br /> EmaiL Phone: ( )� � <br /> f,�I ��� � <br /> Total Cost to Install Device (fiom contractoi invoice): 5 � 'T %`w � - { <br /> i <br /> — � <br /> f <br /> Please veriry the iollowing: � <br /> (�I am lhe owner of the property where the backwater prevention device was installed. <br /> i <br /> i <br /> [�I worked with the contractor to determine the location tor the backwater prevention device and { <br /> nderstand lhat the decision regarding the location of ihe device was mine. � <br /> �My Contractor instructed me how to access, inspect, and maintain the device. � <br /> i <br /> I understand that I am responsible for maintainfng ihe backwater prevention devlce and 1�.eeping ' <br /> it in good working order, unless it is instalted in C:�e ciry right-of-way. � <br /> [�If I sell my property, I will make potential buyers aware of Ihe backwa!er prevention device and <br /> the need to inspect and maintain It on a regular basis. : <br /> [�I am enciosing ail of ihe necessary paperwork (use the yellow Rebate Submitlal Checktist). ; <br /> i <br /> Select from tho following: � <br /> ❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer j <br /> line (between my house and the installed device) and removed, or rerouted them. ; <br /> []�Ta my knowledge,my property has no downspouls or other drainage connected to my sewer line ( <br /> (belween 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 ilooding � <br /> and I accept thal risk. � <br /> � <br /> 1 <br /> I <br /> Signature 2 c � p�2'1(�.L Dale �/ s � <br /> DU ! <br /> I <br /> � <br /> . � <br /> � <br /> I <br />