1109 41ST ST 2022-05-19 - Laserfiche WebLink

i � � Backwater Prevention Device Rebate Program � Rebat2 Application Form � ; Ptoperty Owner Name: c��n 2�1 mfi��2�� rU ;$7"E.V�,�J-$ Installation Address: � � �q � � � ST � City��T State: Le�/� Zip: �j � J Cl / � Mailing Address (if dil(erentJ: / / / l - �l � f/ _ i j City: �v��/T _ State`�(.�1�9 Zip: 9 .�20 / ' , Email: — Phone�(a� a�a -� 'L_`j � -, Total Cost to Install Device (from crontractcrinvoice): S i , .. .. . . . . . . Rlease verify the following: � �J I am the owner of the property v�here lhe backwater prevenfion de'vice was installed. � � I vrorked with the contractor to deteimine the location for lhe backwater prevention device and � �derstand thal the decision regarding the'location of fhe device �vas mine. �-1 e Toc.� ti'E c �.use: 1 �Ca� �-c+ ;cin�ci c.��ou rI� •voc�Ld r�� . �] My contractor instructed me how �o access, inspect, and maietain th'e device: i � I understand that I am responsible for maintaining the backv�ater prevention device and keeping it in good �verking order, uniess it is installed in ihe ciry right-of-way. � If I seG my property, I will make potential buyers a�vare of ihe trackwaterprevention device and the need to inspect and mairtain it on a regular basis ,�f I arn enclosing all of the necessary papenvork(use the yellovi Rebate Submittal Checklist). Sclect from the foilowing: '� ❑ The_coriractor identified downspouts or other drainage Ilines that�vere cannected to my sewer ; line (behveen my house and lhe installed device) and removed, or rerou�ed them: � i �To my knowledge, my property has no downspouts or olher drainage connected to my sew�r line (between my house and the installed device). ❑ There are do�vnspouts or other drainage lines connected to rny sewer line (between my house and ihe installed device). I undcrstand Ltiat leaving these wnneolions creates a risk of flooding and I accept that risk. � � ' � �� Signatur� � � ��, o� U/S -- - ___