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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> � - . _ — —_ --- - — -- <br /> Property Ovmer Name. --- /_a-�1f�v � v� � h _ — <br /> Ins�allation Address 2 3� �� c✓re.t /�_�''� _-_-_--__-_ ._ _ <br /> � --- - <br /> c�iy _ ����� — . . -- si�iP w�. - — zi� -�� v , <br /> Maihng Address �rl diHrrenff -- -------- --- -----__ ,I <br /> Ciry: _ .— _—__ Slate:_ Ilp: - ---- --- I <br /> i [mail: �_�rr<_/c S�Ff .i��_wr,.�(, c�V•+ ---- Phone: (y2tq �-s'1- /t��/ � <br /> �� Total Cosl lo Inslail Jevice (Irom r.onfractorinvoiceJ 3 p��t3� , �{,�—_ -- <br /> i - _ _ - -- ----- ---- - - -- - _ ._ I <br /> Please verify the following: <br /> [J� I am the owner o1 Ihe property :+here thc back�vater prevention de.vir,e was installed. <br /> f�I v�orked wilh the coniractor to deterrnine Ihe locahon for the backwater prevention device and <br /> ainderslanA that the decision regarding the location of Ihe devir.e was mine. <br /> i <br /> [�� 1y conlraclor inslructed me how to access, inspecl, and mainlain �he device. <br /> [ �understand Ihat I arn responsible lor mamtaming Ihe backv�ater prevention Aevice and keeping <br /> it in yood working order, unless d �s mstalled in th� aty nght of way <br /> �t�lf I scll�rny property, I wdl make pntariinl buyers aware of Ihe backwater prevention devir.e and <br /> Ihe need �n inspec� and mamtain d on a regular basis <br /> Lvf I am enr.losiny all of the necessary papenvork (use the yelloc+ Rebate Subnutlal Cher.kllsq <br /> Se�ct from the following: <br /> [� The conUaclur identilied�downspouls ur olhm di�in,�qe Ilines ihal wrre conner.ted to my sewer <br /> luie (bclween my housc and thc installed devicc)and ren��oved, or rerouted them. <br /> � J To my knrn��ledye, my property has no drnvnspouls nr other dramagn conncr.fed lo my sr.wr.r linn <br /> (between my house nnd Rir, instilled devir,r.) <br /> [ � There�re downspouts or niher drain�ge hnes connected lo my sewer 6ne (betvreen my house <br /> and Ihe installed device) I unAersland that leavmg Ihese connechans creales a rsk of Iloodiny <br /> and I accepl th�l nsk <br /> � /� � <br /> Signafure r v'�P�-�^�^� Dafe �� ?- � S _ <br />