1711 26TH ST 2022-05-19 - Laserfiche WebLink

- - - - - � - -- - - -- - -- -- �---:--- ----- -------- --- - -- i � � � Backwater Prevention Device Rebate Program � Rebate Application Form � � u � / �p I Property 0wn.;r Name: �i vG `�y �i��"4 u �kvN.�_( i.`�hd'�� i �,g,c Installation Address: � �/� Z� r' S7� I City: �'-p�l State: ��'___Zip: �d' Z �� _ Mailing Address;iI diflerent): _ i City:_ State: Zip: Y25 - 259-�ysv , Email: _ Phone: ) Total Cost to Install Device (�rom confractorinvoice): $ � foc . / � Please verify the following: I am the ownar of the property where the backwater prevention device was installed. 1 �worked with the contrector to determine the location for the backwater prevention device and I , understand that the decision regarding the location of the device was mine. � � [�My conlractor instructed me how to access, inspect, and mainlain the device. i understand that I am responsible for maintaining the backwater prevention device and keeping � il in good working order, unless il is inslalled in lhe cily right-of-way. IF I sell my property, I will make potential buyers aware of ihe backwater prevention device and i lhe eed to inspecl and maintain il on a regular basis. � am enclosing all of the necessary papenvork (use ihe yeilow Rebate Submittal Checklisl). ISelect from the follawing: i ❑ The contraclor idenlified downspou�s or olher drainage Ilines lhat were connected to my sewer 1 line (between my house and Ihe inslalled device) and removed, or rerouted them. 1 �, �o my knowledge, my property has no downspouts or other drainage connected to my sewer line I I (between my house and ihe inslalled device). I ❑ There are downspouts or ofher drainage lines connected to my sewer line (belween my houee and the inslalled device). I undersland ihat leaving ihese connections creates a risl<of(looding i and I accept lhat risk. I Signature /.uG�`��'�/�� Date � � �Y' �o �> P�fv�--. .9Fc.c_ il � I I �