1111 41ST ST 2022-05-19 - Laserfiche WebLink

i Backwater Prevention Device Rebate Prograrn Rebate Application Form � Property Owner Name: J. ��/a Gt 2-E�� T��ENS Installation Address: //�/ -�/ S—� S T , Ciry:�L�2G17� __Slale: L+JA Zip:��,C7 / Mailing Address (if dilferent): � City: — State: ^ Zip: . EmaiC Phone: (�g) �5�-�7 � g_ j :. F, ,; ; i Total Cost to Inslall Device (Irom contractorinvoice): $ � - I � , � Please verify the following: � , � . �i] I am ihe o�vner of thz properly where the backv�ater prevei 3icn deyice was installed. � _ �, . �.] I worked with the contractor to determine ihe Iocation for the backwater prevention deyice and i understand that the decision regarding the loca;ion of the device e�as mine.--N� ,-o � mE, �¢ �a...�.a:.i .L ha d �t o i d� a t,v f`�u t�,.; s w o t,�tcZ 0 D , ; � My conlractor instructed me hov! to access, inspect, and maintain the device. � , � ' � I under�tand that I am responsible for maintaining ihe backwater prevention deJice and keeping I' - it in good working order, unless it is installed in the city riglit-of-e✓ay. '� ' ,� � If I sell my property, I v�ill make potential buyers a�vare of thc backwater,prevention device and � the need to inspect and maintain it on a regular basis. I . • ! `� I am enclosing all oi the necessary paperwork (use ihe yellow Rebate Submittal Checklist). � Select fram the tollowing: � ; [� The contractor identi(ied downspouts o� other drainage Ilines thal were cunnected to my sewer iline (between my house and the inslalled device) and removed, or rerouled them. � �] To my knowledge, my property has no downspouts or other drainage connected to my sewer line (between my house and the inslalled device). I There are down'spoutg or other drainage lines connected to my sev�er�ine(between my.tiouse � and the installed device). I undersG3nd ihat leaving these connections creates a risk of flooding � and I accept thal risk. . � ' Slgnatu�� ' ate �"'-� / U, �,p /S � � � � � _ - - _ _ _ _ - - f