Laserfiche WebLink
, <br /> i <br /> d75 717)056 03A?Ca pm CE-U7-1015 1 i6 <br /> 1 <br /> ' <br /> ,( <br /> Backwater Prevention Device Rebate Program � <br /> � Rebate Application Form i <br /> � <br /> � <br /> � <br /> I Propetly Owner Namc: u���l �OAGh � <br /> InstallslionAddress:, 1�'�� f_elb., �1ut ! <br /> City: �.�C�t�' Slale: w�' Zip: �� -I��� ; <br /> btai'ing Address(if tlitlerenQ: � <br /> Ciry: slato� 2ip• ; <br /> Email: G�S p d Y. wN¢tk���^G��• �w`'� Phone�(4�S � 26i - 0�4°.� ; <br /> �Ia � (k�M:��+i� i <br /> Tatai Cosl to�nslall Device(hom conlraclorinvoiceJ:b � l lq � � <br /> , <br /> Pleasa verity lha foilowing: <br /> � I am the oHnnr ot the property where the 6adcwater prevenlion device was lnslalled. '� <br /> (� I worked wllh Iho coalractor lo detertnine the location for Ihe backwster prevention device and � <br /> unders�and Ihal lhr.dectsion regarding Ihe iccalion o(Ihe device was mine. <br /> Q My comraclor inslru:ted me how to acwss,inspecl,and malntain Ihe device � <br /> � I undersland Ihat I am responslble for maintaining Ihe backwaler prevenlion device and keeping � <br /> �t In good working order,unless it is instalted In Ihe wry righl�aFway. ; <br /> � !I I sell my property,I wlll mako pateNiai buyers a+vare ol Iha backwaler prevenllon device and � <br /> the need to insp�til and maintain il on e regWar 6asis. , <br /> � I am enciosing all ot Ihe necessery papenvork�use Ihe yeltow ReSale Submitlai Checklisq • <br /> Soloct trom tho foliowing: I <br /> Q' The conhador itlenlif�ed tlownspouls or alher draina�e Iliaes Ihal were connected to my sewer ! <br /> line(6eh+rcen my house nnd Ihe inslallad device)and remaved,or rmauled Ihem. � <br /> L] To my knowledge, my properry has no downspouts or olh�r arainage connectod to my sewer lino � <br /> (behveen my house and Ihe installed device) � <br /> i <br /> [1��There ara tlownspouls or other drainagc lines tonnecicd lo my sewer Ifie(beN.�een my house <br /> and Iho instaVed tlovice).I undersland Ihat Ieaving Iheso connodions treales a nsk ol0ooding � <br /> and I nccept Ihal risk. � <br /> i <br /> ,e���� ��LOlu'vf'� DaM Jr�31�1� � <br /> - Signat�ro , <br /> � <br /> i <br /> I <br /> � <br />