Laserfiche WebLink
'PA Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: 6.#,� <br /> Installation Address: ,2--\. O' ) `�` <br /> Ci c--- State: LA-Vil Zip: <br /> L <br /> Mailing Address(if different): 2-S- J - q--/7"' <br /> " S 6=-- <br /> city: <br /> City: --r- State: - Zip: <br /> 9d1--6S— <br /> Email: <br /> Phone: ( ) _5.--C f- 674-"Z3Z- <br /> 3 <br /> Total Cost to Install Device(from contractor invoice): $ 4_ <br /> � . • 0 <br /> Please verify the following: <br /> Vam the owner of the property where the backwater prevention device was installed. <br /> VI/worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> R/My contractor instructed me how to access, inspect, and maintain the device. <br /> VI understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> al/ff.I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> ❑ I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> The contractor identified downspouts or other drainage 'lines that were connected to my sewer <br /> line(between my house and the installed device) and removed, or rerouted them. <br /> ❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> D There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Signatu - :7 I ell Date !-, 3 <br />