2201 MCDOUGALL AVE 2017-10-20 - Laserfiche WebLink

I i z i Backwater Prevention Device Rebate Program I Rebate Applicata®n Form ' as 1 Property Owner Name: ✓✓✓ ! r ice... Gt 1"r ? Installation Address: �� d l _17 u e �rr 9! 212,0 r t City: b dT` State: Zip:_ r Mailing Address (if different): i City: State: Zip: t i Email: Phone: ( ) Total Cost to Install Device (from contractor invoice): $ ` i ( Please verify the following: QUI am the owner of the property where the backwater prevention device was installed. 2�I worked with the contractor to determine the location for the backwater prevention device and i understand that the decision regarding the location of the device was mine. z ©' y contractor instructed me how to access, inspect, and maintain the device. []-t"understand that I am responsible for maintaining the backwater prevention device and keeping F it in good working order, unless it is installed in the city right-of-way. Zf I sell my property, I will make potential buyers aware of the backwater prevention device and the need to inspect and maintain it on a regular basis. l 0/1"am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). k Select from the following: y [] The contractor identified downspouts or other drainage(lines that were connected to my sewer # line (between my house and the installed device) and removed, or rerouted them. t [ moo my knowledge, my property has no downspouts or other drainage connected to my sewer line (between my house and the installed device). ❑ There are downspouts or other drainage lines connected to my sewer line(between my house and the installed device). I understand that leaving these connections creates a risk of flooding and I accept that risk. Date Signature 1 i i