Laserfiche WebLink
Backwater Preyention Device Rebate Program <br /> Rebate Applicatlon Fonr� � � <br /> Pt�pertyOwnerNama: �m 1��-Lc�yQ11� ��t i ,�� <br /> Instellation Address: .�0.3� �Q.�iS � <br /> City:�V12�'t . State: t--� ' Zip: � �- J3 I <br /> MaBing Address(i1 ditferenf): . <br /> Ctty: Stete: Lp:_ � <br /> � <br /> Emnil: �aLO�� Phono: (Z�9� ���'ZCQS I <br /> ���1 �_�Q�^ i <br /> Total C c co �Sr�u e���r��r,�rn��:s :� 8 o R - �.--�- <br /> Please vetify the tollowing: , <br /> �am the awner of the properly where lhe backwater prevention device wns Instailed. <br /> �worked wilh the oontraclor to determine the IocaUon(or t�e baGcwater prevention dwic�anA <br /> urderstand thet the docisin� regarding the bcaUo�of the device was mine. . <br /> �My conlrador instruded me how to acoess, tnspecl, and maSntain lhe da��ice. -' ! <br /> ��nderstend that I am responslble for maintaining Ihe backwater provenUon device:,nd keeping . <br /> It In good world�g order, unlesa it is installed In the dty rlghtof-way. <br /> [�I sell my property, I wiq make p�ta�dial buyers awere of lhe backwater preve�tion devico and � <br /> Ihe need to inspect and meintein it on a regular besls. � <br /> / [�J"I om enGosing all of tfie necessary paper+vork (use the yellow Rebale Submlttal Chedclisf). <br /> 8elect from the following: I <br /> ❑ The contractor identfied downspouts or olher drainage IOnes that were conneded lo my sewer <br /> line(between my haae erxf the instelled devlce)and n.moved,or rerouled lhem. <br /> �my knowiedge, my property hes no downspouls w other dralnage connacted to my sewer Ilne <br /> (beMreun nry house end lhe inslelled devlce). ' <br /> ❑ There are downspouts or olher drainage Iines connected to my sewer line(between my house � <br /> urd tho inWnibd davice). I understand that leaving these connectians creates a dsk of flooding � <br /> • and I acoopt ihat risk. i <br /> � <br /> Signaturo �j4.�-'� Date C 0"�-�.`�.� <br />