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i <br /> . � <br /> � <br /> i <br /> �� Backwater Prevention Device Rebate Program '• <br /> �w✓/�„ Rebate Application F��rm � <br /> .�_.. ; <br /> {� — i <br /> PropertyOwnerName: ((ZZ 1C(JVJ�h��J � <br /> I <br /> Insta�lation Address: S�d �L V t R S OJU gL �I� j <br /> Ciry: E V�= R�� State� W�_Zip: `9��� ( <br /> Mailing Address(rf dillerent): � _ _ I <br /> ��y; State: �p:� . � <br /> EmaiL•�1177Y�U�fI�h���Q �CJGIQnGl �O�f��Phone� ) Y�� ZJo —IU � i <br /> Tota'Cost ro Inslall Device(from coMracrorinvolceJ: S I <br /> I <br /> Ple�se verify the tollowing: ' <br /> �am the owner oi the property where the backwater prevention device was installed. j <br /> �worked wilh Ihe cantractor to determine lhe loCation tor ihe backwater prevenlion device and i <br /> undersland that Ihe decision regarding ihe location ol lhe device was mine. � <br /> �My contractor instructed me how to access, inspecl, and maintain lhe device. i <br /> I understand that l am responsible for maintaining ihr. backwater prevention device and keeping � <br /> it(n good working order, unless il is inslalled in Ihe city right-o(•wa� � <br /> il I sell my property, I will make potentiel buyers aware ol fhe backwater prevention device and � <br /> the�eed lo inspect and maintain ft on a regular basis. ' <br /> �m enclosing all ol Ihe necessery paperwork(use Ihe yellow ReDate Submittal Checklisl). � <br /> Solect rom the(ollowing: � <br /> The cantractor ldentiAcd downspouts ar other drainage Ilfnes Ihat were connocted to my sewer � <br /> li between my house and thQ installed dewce) end removed, or rerouted ihem ' <br /> To my knowledge,my property has no downspouls or other drainage cannecled to my sewer Ilne i <br /> (between my house and Ihe installed device). <br /> ❑ There are downspouts or olher drainage lines cannected to my sewer Ilne(belween my hause <br /> and the inslalled device)y understand Ihat leaving ihese conneclions crea�es a risk of ilooding ; <br /> and I accept that risk. , ! <br /> � <br /> � <br /> 5lgnature Dafe / � � �� ' <br /> � <br /> . � <br /> t <br /> � <br /> . i <br /> i <br /> I <br />