1201 41ST ST 2018-12-27 - Laserfiche WebLink

477. Backwater Prevention Device Rebate Program Rebate Application Form Property Owner Name: %1(Y) R Installation Address: I q/ 54- 5i-- City: / State: c.,.9 Zip: Mailing Address(if different): City: State: Zip: Email: Phone: ( ) Total Cost to Install Device(from contractor invoice): $ Please verify the following: .I am the owner of the property where the backwater prevention device was installed. I worked with the contractor to determine the location for the backwater prevention device and understand that the decision regarding the location of the device was mine. My contractor instructed me how to access,inspect,and maintain the device. l I understand that I am responsible for maintaining the backwater prevention device and keeping " it in good working order, unless it is installed in the city right-of-way. If l 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. [ Lam enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). Select from the following: ❑ 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. ❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line (between my house and the installed device). CI 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. y Signature YdZ a,Date / 4 t