Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Properly Owner Name: ��%C/�� `' ��'�� <br /> Installation Address• ^/�� /"i� �� _ <br /> City/'l '� " ' / State: �N.� _Zip: ���/ <br /> tvlailing Address (il dilferent): <br /> City: Stale: Zip: <br /> Email: Phonel,�� �Z�dl��—" <br /> �� <br /> Total Cost lo Install Device ((rom confractor invoiceJ: S ��5��" <br /> Please verify the following: <br /> .�7f�I am Ihe owner of the property where the baclnvater prevention device was installed. <br /> ,�'I worked wilh the conlractor lo determine the location for the backwater prevention device and <br /> understand ihat the�iecision regarding the location of the devi�e v�as mine. <br /> � My contraclor instructed me how to aceess, inspecl, and maintain the device. <br /> �I undersland thal I am responsi6le for maintaining lhe backwater prevention device and keeping <br /> it in good working order, uNess it is inslalled in the city right-o(-way. <br /> ,�If I sell my property, I will make potential buyers aware of tfie backwater prevenlion device and <br /> Ihe need to inspect and maintam it on a regular basis. <br /> �] I am enclosmg all ot ihe necessary papenvork(use the yellow Rebale Submdtal Checklist). <br /> Select irom lhe following: � <br /> ❑ The conlractor idenli(ied downspouls or olher drainage Ilines lhal were connected to my sewer <br /> line (between my house and the installed device) and removed, or rerouted Ihem. <br /> ❑ 'fo my knowledge, my property ha, no downspouts or other drainage connected to my sewer line <br /> (belween my house:�nd ihe inslalled device). <br /> �j There are downspouls or other drainage lines connecled to my sewer line (between my house <br /> and fhe installed device). I understand that leaving these connections creales a risk of flooding <br /> and I accepl that risk. <br /> � � > <br /> Signature � -� �afe bJ + ��� '/� <br />