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i <br /> � Backwater Prevention Device Rebate Program ; <br /> Rebate Application Form ; <br /> --- 1 ----- - ; <br /> Property Owner Name��5�✓� n2'7���'�1 <br /> _. � <br /> InstallationAddress� � Z�o p Yo f 1���� <br /> c+cy:�vti�1� state� 4Jl� _z�P�Fi'KLo_1 <br /> Mailing AdAress(i1 diflerenf�: <br /> Ciy: Slete: _Zip'_____.___ <br /> Emall� r�c.��5on.��\el�\e ti�-� q�,`,Co..� Phane: �7S)1�b' G��3 ' <br /> J�,- <br /> ITotal Cost lo Inslatl Device(/rom contracforir�wice)�S n7�,3l. �� ' <br /> Ploaso vorlfy tho following: � <br /> � I am the owner ot the property where the backwaler prevention Aevfce was installed. <br /> [J I worked with ihe conlracror to determine the loca!'on for ihe backwaler prevenlfon device and <br /> understand Ihat Ihe decisian re�7arding Ihe Iocatian of Ihe device was mine <br /> �j My contraclor inslructed me how la access, inspecl,and maintain the devico ' <br /> � 1 undersland ihal I am responsible lor maintaming lhe backwaler prevention device and keeping <br /> it in good working order,unless it is installed in the cily right-oi-way. <br /> �J II I sell my properly, I wiU make potenlial buyers aware of Ihe backwaler prevenUon device and � <br /> thc need to inspecl and mainlain il nn �reguiar basis. <br /> � I am enclosing all ul Ihe necessary paperwoik(use the yellow RQbate Submittal Ctiecklisl). <br /> 3eloct lrom tha lollowing: � <br /> (� fhe contraclor identified downspouls cr olher drafnage Ilines Ihnt were connected to my sewer <br /> linc(bclween my house and the installed device) and removed, ur rerouted them. <br /> p I o rny knowled�e, my propr.rty has no downspouls or olher drainafle connected to nry sewer hnr. <br /> (hetween my house and the inslelled devia:). <br /> ❑ 1 hcre arr.downspouls or othe� dralnaye lines wnnected to rrry sewer linc(belween my house <br /> and the Inslalled device). I undersland Ihat Ieaving these connoctions creates a risk of Ilooding ' <br /> and I accepl that risk <br /> S(gnafure�/"�'.X�'� �le��Dafe �'L.� ' �S <br />