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�,�/�'' Backwater Prevention Device Rebate Progr�m <br /> �iw�,.� Rebate Application Form , <br /> .�,�„ <br /> �-- ---- --- ----- <br /> --- - -- -- <br /> Property Ovmer Name _�l hL2 W 1 I�� . <br /> Inslaliation AuJress:_��� t X'a cP'r GtUC. _ , <br /> City ��S'5..�Staie �-1�—t�P: C����C 1 _ i ' <br /> i <br /> Mailing Address (i/diHemnt�: ---'- <br /> �ih, State:—.� --Z�P /'1 – , , <br /> E, �ail .. �(10.�"00 G�r(Y��'C��1 _Phone (`F��.`i) ����1:� � <br /> 1'ctal Cosl to Install Uevicc (Irom contractorinvoiceJ. S^�.(4 �� ���� <br /> Plcase varify the following: <br /> [(�am the owner of Ihe propem� where Ihe backwater prevenUon device was mstatled. <br /> �'I worked wdh the conlracror to determine the location lor the backwaler prevention device and <br /> understand Ihal lhe decision regarding Ihe localion of the device was mine. <br /> �{'My wnlreclor inslructed me how to access,inspect,and maintain the device. <br /> [f} I undersland Ihat I am responsible tor mainlaining lhe backwaler prevention device and keepin9 <br /> It in good workmg order, unless it is installed in the city right•ot-way. <br /> L If I sell my property, I will make potenGal buyers aviare ol the backwater prevention dev�ce and <br /> th need lo inspect and maintain it on a regular basis. <br /> � ' I am enclosing all o(the necessary papenvork(use the yellow Kebale Submitlal Checklisq. <br /> Solect from lhe following: <br /> �ne (helwee'n my hoase and the s,tal�led dev��e)landeemove�d?or rerouted lhem �o my sewer <br /> � Ta my knawledge, my property has no downspouts or other drainage connected lo my sewer line <br /> (between my house and the installed device). <br /> � andrlhe instal ed device)r I understand iha't leav ng these conneclionsr e eates a r sk ot tloodmy <br /> and I accept that risk <br /> c � �1 <br /> Slgnat re � Date � � �/ <br /> I <br />