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� <br /> � <br /> Backwater Prevention Device Rebate Program � <br /> Rebate Appl(catfon Form i <br /> I <br /> � <br /> PropeAy Owner Name: �re o/C�• "� f(� ��' <br /> InsfallationAddress� ►Sz7 �2��e.� /��e . � <br /> � <br /> c�H: ��elz F{- s�a�e: !,✓vf _ z�P� 9�a ( � <br /> Mailing Address(ll dlHerenQ: 1 � <br /> � <br /> ctry: State: _zip: ; <br /> I <br /> Email: Phone: (��) ��- —��4� � <br /> - � <br /> Total Cost to Install Device (/rom confractorinvoice): S ' <br /> � <br /> i <br /> Pl�aso veriry the followlnp: +� <br /> �am the owner of ihe property where the backwater prevention devlce was installed. i <br /> �worked with Ihe contractor to determine the location for the backwater prevenlion device and � <br /> understand that the decision regardi�g the location o1 the device was mine. � <br /> �My contraclor instructed me how to access,inspect, and maintain the device. ` <br /> �undersland Ihat I em responsible for maintaining lhe backwater prevention device and keeping i <br /> il in good working order, unless it is installed in lhe cfry right•ol-way. � <br /> Ii I aell my property, I wlll meke potentiel buyers aware of the backweter prevention device and j <br /> the need to inspect antl malntain il on a regular basis. I <br /> � am enclosing all of the necessary paperwork(use the yellow Rebale Submittal Checklist). ; <br /> 1 <br /> t <br /> S�lect from the followinp: ; <br /> �The cantractor idenlified downspouls or other drainage Ilines that were connected to my sewer ; <br /> Iine (between my house and the installed device)and removed, or rerouted Ihem. ' <br /> �To my knowledge, my property has no downspuuts or olher drainage connecled to my sewer line � <br /> (behveen my houso end the instelled device). i <br /> i <br /> ❑ There are downspouts or othet drainage Ilnes connected to my sewer line(behveen my house <br /> and the Installed device). I understand that leaving ihese connections creates a rlsk of Ilooding � <br /> and I accepl lhal risk. � <br /> � <br /> i <br /> I <br /> S►ynaturo�J�-a- .%— ��-� Da�e_ 3//91 r-�' � <br /> v , <br /> 1 <br /> i <br />