Laserfiche WebLink
GCT-23-2015 08:59 From:14253770625 Paee:1�5 <br />� Backwater Prevention Device Rebate Program <br />Rebate A�plication Form <br />PropertyQwnerName:l��\1��LL JLIvh�SU�A l��f\d �i-pX <br />Ins�Hation Address: � ��J �-��y �Y� �r <br />CnY: EV�e�f-e�{ State:l.tJ%t Zip; a�i %'� _ <br />Mailing Address (if diti'eren�): <br />City: Stale: Zip. <br />Ernal��fy�'1ih.Q2�9�n�-I�-�+�gVnaal. Phane;('%{� �l�{ L�CCo'L <br />to1M <br />Total Cost to Install Device (Imq� coMradorinwiFe): S <br />Please verify the falloWing; <br />� I am the awner of 1he property where the badnvater prevention device was Inslalled. <br />i� ! worked with the contractorto detamune No foration for tho backwster preveniion devlce and <br />� understend that the decfaan reg2rtling the Inpdon of t�1e devlce was mine. <br />❑ PAy �antrac(or instcucted me hwr to aocess, inepect, and mairrtain ttte device. <br />�.i understantl that 1 am respansiDle for malntaining thg Daekwater prevenUon Qevica and keeping <br />if jn good working ortfer, unless it i, tnsta�ed in the ctty rigM-of-way. <br />� If I sell my p� �Qerty, t whl maka pot9rNal buyers a+yare of Ihe backwater preverttion davice and <br />the need to inspact and malntain it on a repular basis. <br />� I am encbsing oll of the neceRaary papernork (use the yeilow R�bate Suhmiqel Checklisl). <br />sclectrrom the following; <br />❑ The contrador identified dowrtspouts or other drainage llines thal were connecled to my sewer <br />line (between my houae ond tha installed dovice) and removsd, or rerouted Ihom. <br />�To my knowledge, my property has no downapouts or othcr dralnage wnnecUjd ro my sewar line <br />(bohveen my house and the insleued deNce). <br />❑ There aro downspouts or olher drainage Iines connected ro my sewer line (between my house <br />and the instelled device). I understand thst leaving lheso connectlons creates a risk of flooding <br />and I aoGept t�et rlsk_ <br />---'� o - 23- r5 <br />SlgDstu Dafe � <br />