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I ' - <br /> � <br /> � <br /> ! Backwater Prevention Device Rebate Program <br /> ' Rebate Application Form <br /> Property Owner Naiue:�,{�� ' . ��l.JL/ _ <br /> i Installation Address: �J 3 1 ALY <br /> City._��' ,�,�5.�---Slate: \21� Zip: I aa �� _ <br /> Mailing Address(il dillerent): <br /> � -- <br /> Cily; Slato: Zip: _ <br /> Email:,�g �m��V � Phone: (yl)) �j► �30 I <br /> � <br /> Total Cosl to Install Dzvice(Irom co7trectorinvofce):$�r�`C� � <br /> Please veri(y the followiog: <br /> i �I am lhe owner of Ihe property whe�re lhe backwater prevention device�vas Installed. <br /> I � I worked with iho conlractor to detorrrifne the locat(on for the backwaler prevenlion device and <br /> understand that tho declslon regar�ing ihe location ot ihe devlce was mine. <br /> ❑ My coMrar,tor inslrucled me how lo access, inspecl, and maiotain fhe device. <br /> I I understand lfmt I am responsible for maintaining Ihe backwater pr3venlion device an 1 ke�ping <br /> il in good working order, unless it Is inslallod in tho ciry ri�ht-of-way. M <br /> ! �If I soil m <br /> y proporty, I will make potentfal buyers awaro o(thn backwater prevention dovice and � <br /> fhe need to inspect and malntain il on a regular basis. <br /> i <br /> i ❑ I am enclosing all ol Uie necessary paperwork(use lhe yellow Rebale Submillal Checklisl). <br /> Solect Irom the following: <br /> � [ � The contraclor identified downspouts or oUier drainage Ilines that were connected to my sewer <br /> � line(betwc�n my house and Ihe inslalled device)and removed, or rerouted them. <br /> I � To my knowledge, my properry has no downspouts or olher dralnago connecled to my sewer Ilne <br /> (behveen my housc and the installed device). <br /> I ❑ There are downspouts or olher drainage Ilnes connncled to my sewar line(6etween my house <br /> and the installed devicc). I undnrstand ihat leovin� these connections creates a risk oPOoodin� <br /> andlacceptthatnsk. <br /> � ` JG� 6/q �s <br /> Signature � `� Date <br /> I <br /> i <br /> I <br /> � <br /> I <br /> � <br />