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Backwater Prevention Device Rebate Program <br /> 4.77, <br /> Rebate Application Farm <br /> / 75/„c4._a '. ' <br /> Property Owner Name: ,, <br /> eiti .' <br /> Installatior . i? e572(. 7,:), <br /> �Address.� -��1.�� <br /> ort <br /> City: ., State: Zip: <br /> ts, Mailing Address (if different): - - %r r <br /> City: State: Zip: <br /> 4 Email: Phone: ' /k Li <br /> Total Cost to Install Device (from contractor invoice): $ <br /> i <br /> Please verify the following: ,tri*/'', `' <br /> s <br /> [ I am the owner of the property where the backwater prevention device was installed. <br /> ,i 0I 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 /> My contractor instructed me how to access, inspect, and maintain the device. <br /> 1 understand that I am responsible for maintaining the backwater prevention device and keeping <br /> • <br /> ' it in good working order, unless it is installed in the city right-of way. <br /> If I sell my property, I will make potential buyers aware of the backwater prevention device and / <br /> g � the need to inspect and maintain it on a regular basis. <br /> x <br /> I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal checklist}: <br /> <N Select from the following: <br /> • <br /> Li, . The contractor identified downspouts or other drainage Mines 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 /> LI 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 /> k <br /> �, ,, i <br /> /f <br /> Signature <br /> ce 4' , ;;f.-- _ Rafe <br /> .,tom ✓� G, ,, ;.. • t` <br /> y 3s�y ^" ti �. t -u r moi; a"�' � '� ? s z:. • <br /> :''r;Y a w Fn � 'f`5`` r F,3 �' 'fr ,,\" 3"s -!_ '.-, ', Y• • P� i� oak,, �� v <br />