1813 OAKES AVE 2016-01-01 MF Import

----- -------- ---- _ —._______ --- ---- -- �- -.�--- . . . -- --_- --- __ _ Backwater Prevention Device Rebate Program Rebate Application Form Property Owner Name:L� � � �� Installalion Address: �'�JI � DAI�-C�S .L1✓P. City: �✓�0✓P/T State: _�_7_ip: ��aYI tviailing Address (if dil(erenQ: a-/GIO� ��` Q✓(�. Uv. City:�P�e%1 State: �'1�,� Zip: lr�� Email: SYCL�r��(�/.��R1� ,�C7�'1^- Phone: (7� ��33d Total Cost to Install Device (frorn contractor rnvoice): 5 P�O �� Please verify the following: �] I am the owner of the property where the backwater prevention device was ir„tailed. � I worked with the conlractor to determine the location for lhe backwater prevention device and understand tliat the decisioi� regarding the focation of the device vias mine. ❑ My contractor insiructed me ho�v to access, inspect, and maintain the device. ❑ I understand that I am responsible for maintaining lhe backwater prevention device ancl keeping it in good Norking order, unless it is insta�led in the cily right-of-way. ❑ If I sell my property, 1 witl make potential buyers aware o(the backwater prevenlion device and the need lo inspect and maintain it on a regular basis. ❑ I am enclosing all of the necessary paperwork (use the yellow Rebate SubmiCal Checkiist). ` ' Select trom the tollowing: ❑ The coMractor identified downspouts or other drainage Ilines that were connecled to my sewer line (between my house and the inslalled device)and removed, or rerouted Ihem. �. To my knowledge, my properry has no downspouts or olher drainage connected lo my se�ver line (between my house and the installed device). ❑ There are downspouts or other drainage lines connecled to my sewer line (between my house and the installed device). I understand that leaving these connections creales a risk of flooding and I accept that risk. ' Signature ___Dafe � `2�—� �