Laserfiche WebLink
� BackwatPr Prevention Device Rebate Program <br />f�`.�bate Application Form <br />� _ --- ---- --- - --- — �_ <br />PropertyOwnerName: I"i�(�n4{.� �',�4hp 3�GE� �-c.)c,.�� <br />Instaliation Address: <br />� ���1'� State: <br />-- Z�P�— <br />4lailing Address (i1 dilferen!): <br />� ���Y� Slate: <br />Zip:_ <br />I EmaiL• i_ _ Phone: ( <br />I7btal Cost to Inslall Devlce ((rom con�ractor involce): S <br />Please verify Ihe following: <br />�I am tne owner of ihe property e�here the back�vater preventian device �vas Installed. <br />r.,�t a�orked �•nth the wnlractor to determine Ihe ocaticn for the back�vater prevention device and <br />underslantl that the decision rr.gardir,g the localion of Ihe device was mine. <br />[�i Yy conVactor instructed me how to access, inspect, and maintain ihe deviCe. <br />fy�l understand U�at I am responsible for mainlaining ,he back�vater prevention device and keeping <br />it in good tit�orking order, unless il is installed in ihe city right-of-e+ay. <br />[�I` I sell my property, I will make potential buyers aware of the bacfcwater prevenlion device and <br />fhe need to inspect and maintain it on a regular basis. <br />i� �I am er.closing all of Uie r,ecessary papenvork (use lhe yellow Rebale SubmiUal Checklist). <br />Select from the following: <br />I_� <<�e contractor identified downspouts or other drainage Iiines lhat were connected to my ,ewer <br />line (behveen my house and thc inst�lled dcvice) and removed, or ierouted Ihem. <br />IL�i To rny kno�vledge, my property has no dotvnspouts nr other drainage connected to my sewer line <br />(betti��een my house and Ihe inslailed device). <br />j� 7here are downspouls or other drainage lines connected to my sewer line (betvaeen my house <br />and the instalied device?. I underslarid that leaving these conneclions creates a risk of Oooding <br />and I accept Ihal risk. <br />Date �(i 17 - I � <br />