710 47TH ST SE 2022-05-19 - Laserfiche WebLink

, ! Backwater I�reventi�n Device Rebate Program ' F�ebate Rpplication Form + I � I --- - — IProperty Owner Name: -�d 4'+n ��4 n� �i Installation Address: �1 U `�/ 7 S i S t ', City: �=-d c-t if _._ Stale: _L,1,'�._Zip:��7�3 I � Mailing Address (il differen!): _ _ __ Ciry: _ State: _._.Zip:_ � EinaiC ,�,bn<�� he�.'fho— C� c��mc4;,f, ner Phone: (vis1 �5i -93w____ ' Total.Cost to Install Device (irom contractorinvoice): 5 ar y yy 5�1 I � L — - ---- --- --J l � Please ve�ify the following: j [�I am Ihe owner of Ihe property where the backwaler prevention device was installed; � [�I worked �vith the conlractor lo delermine the location for the 6ackwater prevention device ar.d ! understand that the decision regarding the location ot lhe device v�as mine. ' [� tviy contractor instructed me how to access, insoect, and maintain the device. [�I understand that I am responsible for maintaining Ihe backvdater prevention device and keeping it in good working ord'er, unless it is installed in-the city righ:oi-way. ; [� If I sell my property, I ivill make potential buyers aware of the backwaler prevention device and the need to inspect and maintain it on a regular basis. � � I am enclosing all of the necessary papenvork(use Ihe yellow Rebale Submitlal�Checklist). , Select from the following: ' ❑ The conlractor identificd dov+nspouis or olher drainage Ilines lhal v�ere conner,led to my sewer line (behveen my huuse and the�nstalled d'evice) and removed, or rerouted them. � [„�To my knowledge, my property has no downspouts or other drainage connected to my sewer line i , (bel�veen my house and the installed device). ❑ There are downspouts or other drainage lines connected to my sewer line(belween my ho�se and the installed device). I undersland thal leaving these connections creates a risk of flooding and i accept that risk. Signature � L Date b �� , , � I