Laserfiche WebLink
� Backwater Prevention DEvice Rebate Program <br />Rebate Application Form <br />Property Owner Nart <br />Insiallation Address: <br />Ci•.ry' �-N/ZG�d _, State: �U �_ Zip. � c�v / <br />�lailinq Address (rldiRere,it) '�J� C �2�'Z��' �Q�O <br />City: 7 _ Sta;e: C%•N 7_io: i�5�� <br />, Email. <br />To:al Cost to Inslall Dev�ce (lram contractor rnvoic.): 5 <br />I_-- --- --- <br />Plcasc vcrify thc following: <br />Phone: ( ) _ <br />i�7 • .4 r' <br />[� I am tne o�;mer o` the prop�rty vfiere ihe bac't�:ater prevention oevice vras insialled. <br />(� I wor!ced with'he contrac;or to determir.e ihe location for the backtvater prevention device and <br />understand tha; thz dacision regardirq the location oF the device was mine. <br />[� A4y contrador instructed me how to access, inspect, and maintain the device. <br />��I understand ihat I am responsible for mainta!ning the 5ac4ova;er preverticn device and keeping <br />it �n gcod working orde;, unless it is insta!leo in fhe city right-of-way. <br />�'j If I sell my property, I �xll make potential buyers a�vare o` the backwater preventian device and <br />the need to inspect and maintain it on a regu:ar basis. <br />�' I am enclo>ing ail o( ihe necessary oapenvork (use the yellow Rebate Sutmittal Chechlisp. <br />Select frorn the !ollowing: <br />�`� The contractor idenli(ed downspouts or other drainaoe Ilines that c�ere connec,ed to my sewer <br />line (bcN.�cen my housc and fhc inslalled device) and rernoved, oi rciouted �hem. <br />I <br />�i To my knowlecige, my preperty has no downspou!s or other drainage connected lo my sewer Ilnz <br />(between my house and the installed devicc� <br />j� 7here are downspouts or other drainage lir,es connected to my sewer line (between my house <br />and Ihe instal!eA device). I understana that leaving these connections creates a risk ol Pooding <br />and I accepl fhal risk. <br />•-- /� <br />Signature _____ Date � t� //f _ __ <br />f._ <br />��TuL �'on.�f-�crrU�/ <br />�9��-s.� � a.0 <br />