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1 <br /> I <br /> � <br /> , Backwater Prevention Device Rebate Program ; <br /> Rebate Application Form ' <br /> ----- ------ -- -- - -- -- � <br /> Propr,rty Owner Name.: / �/1(' 4 _i�}�---_- � <br /> -- , --- - _- - � <br /> Insl�IlationAddress: �-�72___T�vh�-�_��- _____� __ . j <br /> City �v�v`C��-- --State —(' _ ___ Z�P --1�i�� -- - -- � <br /> - , <br /> Mailiny Address (i(ddlerenf): _____ _,____ I <br /> I <br /> City'-- _ _ ,__ -- _ State: ---- Z�n' ------ � <br /> Email: _ -------- ----- -Phone: ( )__ _ J <br /> Tolal Cosl lo Inst�ll Device(fiori confrar,lor invoice): $ _ _ _________._______ i <br /> � <br /> -- -- --- -- --- —_ _ _ _-- � <br /> I <br /> Please verify the following: ; <br /> �I am the owner of lhe property where Uie backwater prevention device was installed. i <br /> l�' � <br /> '� I worked v,ith the conhaclor in delermine the localion lor Ihe backwatr.r prr.vention device and <br /> understand lhat the der.ision regarding ihe location of Uie device was mine. , <br /> �My contraclor instruded me how(o access, inspect, and maintain the device � <br /> �{ I understand that I am responsiblr,for maintaining Ihe backwa(er preven6on device and keeping , <br /> it in good vrorkin,y order, unless il is inslalled in lhe city right-of-way. � <br /> � If I sell my pmperty, I ��eill make pofential bcyers av✓�re of the backwalr.r prr.venNon device and ' <br /> the need to inspr.r.t and maint.ain it on a re,yular basis I <br /> � I am endosiny alt of the ner,�ssary paperwork(use Uie yellow Ret 3to Subrnill�l Checklistj. ! <br /> Sclr.cl from thc following: � <br /> � <br /> �_� I he conlra�dor idenitli�d duwnspuuts or nlhei drainaye Ilmes thal were connecled �o my sev�er � <br /> linn(helwei�n nry hnusr. and Uu� mst�dled device) and rernnved, or mruuted �hr,m � <br /> ,�'[/I Tu nry knov�lc,f�c, my properly has no downspmds nr olhc�r draimhr, r.onneclr.d lo my snwr.r hne <br /> /\ (br.lween nry hnuse and lhe insta!led devir.e). ' <br /> I <br /> ❑ There are downspoul5 or olhe� drainage linr,s r.onnected to my sewr.r lu�c (behvicen my hause <br /> and Oie inslalled d�.vir.n) I understand Ihat leaving Ihosr.rnnnections ueatr.s .i nsk of Iloodiny <br /> .�nd I accept�hat risk. I <br /> i <br /> Sirnafiuc�r�� �������� ����-��._ ' <br /> / -�1���--- <br /> J l�_n�'�L Oafr. J'" � <br />