Laserfiche WebLink
_--.--- -- - -_.__—.� --- - --`��,_ —_�.___ <br /> Backwater Prevention Device Rebate Program <br /> E,, Rebate Application Form <br /> _� <br /> Property Owner Name: JQ V.� �X�i ✓ �YLG(�' l <br /> Installation Address: � � � � ��S �"�"�'-e' - <br /> c�tv: EUe2L�� State: �Zip: �2O� <br /> Mailing Address(if diKerent): <br /> Cily: _ State: Zip: _—– <br /> Email: Phone: ( ) <br /> Tolal Cost lo Install Device (Irom contractorinvoice): $_�/y�� . � _ <br /> Please verify the(ollowing: <br /> �I am the owner of the property where the backw�ater prevention device was installed. <br /> ,�I worked with lhe conlractor to determine the location for Ihe bacF;waler prevention devioe and <br /> understand that the decision regarding the location of lhe device was mine. <br /> � My contraclor instructed me how to access, inspect, and mainlain ihe device. <br /> �I✓ I uno�rstand that I am responsi6le for maintaining lhe backwater prevention device and keeping <br /> ����� it in good working order, unless it is installed in the city rlght•o(-vray. <br /> � If I sell my property, I will make polential buyers av�arc oi lhe backwaler prevention device and <br /> the need to inspecl and mainlain it on a regular basis. <br /> � I am enclosing all of the necessary paperwork (use the yellow Rebate Submitlal Checklist). <br /> Select from the following: <br /> , �The contraclor idenlified downspouls or other drainage Ilines thal were connecled to my sewer <br /> line(belween my hou;e and lhe installed device)and removed, or rerouled them. <br /> ,��To my knowledge, m� prope�ty has no dovmspouts or othctr drainage connecled to my sewer line <br /> (between my house and Ihe instatled devics). � <br /> ❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and the installed device). I understand that leaving these conneclions creates a risk of Oooding <br /> and I accept that risk. <br /> / <br /> � � <br /> Signature - ii ��j`� Date � �f __ <br />