4202 COLBY AVE 2016-01-01 MF Import

i . � � i � Backwater Prevention Device Rebaxe Program � �w�F,., Rebate Application Form ' J--- i -- `�. `_ 1 I PropeRy O�mer Name: J'-2�S�C.)i v1�C'/� 1 ' t�s-��.t 1 ' InslallationAddress: ��C7a ��'� ' "�� • � n i Ciry• �t �f�F'`�� State: l.C) ft Zip: ��C�) � __ ; Mailing Address(it d;flerent):�� !Ct l'� �� 'S� _ , I � � ; City: � �%f��'��' Slate: c,c7 �4- Zip:��'�1� � Email: Phone: �� l7 -�� L��., Total Cost lo Install Devicc (Irom cantraclorir.wlce): S c�`t�i�•� � Pleaso verlfy the following: [,�I am lhe o�vner of ihe property where the bac w:ater prevention device was instailed. ❑ I worked with the contractor to determine the bcation for the bacicwaler prevention device and understand thal ihe decision regarding the location of the device wns mine. ❑ My conUactor insWcted me now to access,inspect,and maintain the device. � ❑ I understand lhat I em responsible for maintaining the 6ac{avater prevention device and keeping it in good working erder, unless it is installed in the city right-of-way. ; ❑ If I sell my property, I will make potenlial b�ryers aware of the backv+aler prevention device and the need lo mspect and maintain It on a regular basls. � � ❑ I am enclosing all of Ihe necessary papenvo�k (use the yellov�Rebate Submittal Ghecklist). Salect from the following: I ❑ The coniractar idenlified downspouts or other drainage Ilines lhat were connecled to my se�ver ! line (belv+cen my house and the installed device) and removed,or rerouted them. [�To my knowledge,my property has no downspouls ar olher drainage connecied lo my sewer Ilne (between my house and the inslalled device). ❑ There ate do�mspouts or other drainage Ilnes connecled to my smver line(between my house � and the instaVed device). I understand ihat leaving lhese conneclions creates a risk of Iiooding and I accept lhal risk. ; - � Signature„L �� Date �'' -�`� /S i