1317 HOYT AVE 2017-01-13 - Laserfiche WebLink

� `�; �� } Backv��t�r F�r�v�n�ti�n De�r�ce R�b�te Program ��eba�e Applic�tion Form Property Owner Name: �!i � �.. � � � �� 1.4. .� %��l' � ��t� � ��,�'' � � � Installafion�Address: l`�i I�? � �h�i�Y`� �4��i�'�� � �� City: ,� iJ � � � i �i �� State�; �� !� �� Zip: � t�'�� l �``� 4 � �4 � Mailin� Acfd�ess (if di�fer�nt): � , City: State: Zip; �maiL �1�L�'Cal$��,�5 ��lat�(�.�-�.-UB`�'l Phone: (�i2"�) �-�.�.��'`�t�� Tot�l Cosf to lnstall Device (#rom eonfracforir7valce}: $ �� '"�'_�� Please verify the fotlowing: ' � I am the awner of the property where the backwater preventiar� tlevice was installed. (�( ( worked with the"contractor to determine the (ocatian #or the backwater prev�ntion device and � understand #hat fi�e decisian regarding the location 4f the devi�� was mine. �' � (� My contractor instructed me how to access, inspect, and maintain the deviee. � I understand that 1 am respansible for maintaining the backwafer preventian device and keeping it in gaod working order, unless it is instalied in the city right-of-way. j� If I seli my property, I will make po#ential buyers aware of the backwater prevention device and , the need tc� inspect and maintain it on a regular basis. � 1 am enclosing all of the necessary paperwork (use #he yellaw Rebate Submittal Checklist). Select from the following: ❑ The contractor identified downspouts or other drainage i(ines that were connected to my seaver line (between my house and the installed device} and removed, ar rerauted them. To my kn4wl�dge, my property has no downspouis or okher drainage canr�ected io my sewer line (between rny house and the instalied device}: '❑ There are downspouts or ather drainage lines connected ta my sewer lin�'{between my house and the instafled device). I underst�nd that leaving these connecti4ns creates a risk of floading and I'acce�rt thai risk. � � Signature ��G-�..,..�' `'�c � � 1��:��z.._- Date ��1�� i� � 4 �