2122 COLBY AVE 2016-08-11 - Laserfiche WebLink

Backwater Prevention Device Rebate Program Rebate Application Form Praperty Owner Name: `�f�f' �� C.� � �90 t''� Installa#ion Address: �`} � 2 CJ`�J� �v� City: � li�(�-� State: ��Y y Zip: l� �`� � Mailing Address (ifdifferent): �� b� ��'0� �k— /�.�`C , City: LG�� "�C��,.v�vl� State: wv l Zip: �� - �� EmaiL _C�n� i!��o ��V �� Cv ��}��, �;�� CD;h''�- Ahone: �2� ) ��b � �� S � _ Tatal Cost to Install Device (from contractorinvoice): $ �-y ��' �`� Please verify the fot[owir�g: �m the owner of the praperky where the backwater prevention device was instailed. �worked with the contractor to determine the location for the backwater prevention device and unders#and that the decision regarding the location of the device was mine. [�My contractor instructed me how to access, inspect, and maintain the device. �understand #hat I am responsible for maintaining the backwater prevention device and keeping it in good working order, unless it is installed in the city right-af-way. [�If 1 sel) my properiy, I will make potential buyers aware of the backwater prevention device and the need to inspect and maintain it on a regular 6asis. - [�I am enclosing alI of the necessary paperwork (use the yellow Rebate Submittal Checklist). Select from fhe following: ❑ The cdntractor identified downspouts or oiher drainage Ilines that were connected to my sewer �I' e(beiween my house and the installed device) and removed, or rerauted #hern. o my knowledge, my property has na downspouts or o#her drainage connected to my sewer iine (befween my ho�se and the installed device). ❑ There are downspouts or ather drainage lines conn�cted to my sewer line (between my house and the installed device}. 1 understand that leaving these cannections creates a risk of flooding and I accept that risk. � Signafure fi� .�.!/�( h � .� c�' , �.z--.�,.LT�atsf r� ~� �'7` � ��