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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> —__— _ ----- --_— — <br /> ' '� �- <br /> Property Owner Name: �S�y��1c �-�_��_�ly� <br /> Inslallation AAdress �, 3 � � �.�-_��,�__ ____ <br /> CitY _�'�!/ <�G�� _ _ _ Stale' _��-.._ZiP:___/ � 02 u( <br /> Mailing Address (il diHeient) ___�_ _ ____ <br /> City: __ , __ State: _Zip ________ <br /> ' Emait: iJ I G���N-� � c G h�� . cu•-� Phone (�2S) 3 C7 ��`� 7 <br /> �- � <br /> Total Cost to Install De�� :e (lrom contracfor irrvoice): 5_ �J � <br /> �-- - — <br /> ----- -- - — __ ---__ — ___---- <br /> Please verify the following: <br /> �I am the owner of lhe property where the backwater prevention device was inslalled. <br /> � I worked wilh the conlraclor lo determine lhe locahon for lhe backwater preven6on device and <br /> undersland�hal Ihe decision regarding the localion of the device was mine. <br /> �My conlractor instructed me how to access, inspect, and maintain ihe device. <br /> �I understand thal I am responsible for mamtaining Ihe backwater prevenlion device and keeping <br /> d in good working order, unless it is installed in �he cily right-of-way. <br /> � II I sell my preperty, I wtll make potential buyers awarr, of the backwater prevenlion device and <br /> Ihe eed to inspect and mainlain il on a regular basis <br /> am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> �}� fhe coNractor idenlihed downspouts or other dr�inage Ilines thal were connecled to my sewer <br /> line (between my house and the inslalled device)anA romnved, or rcrouleA Ihem. <br /> �Tn my knowlodge, my property has no downspouts or other drainage conner.ted to my sewer line <br /> �7 '�(bMween my house and lhe installed device). <br /> �There are downspouls or olher dramage lines conner.led to my sewer Ime(belween my house <br /> and ihe installed device) I understand Qial leaviny these runneclions cre:ites a nsk of flwding <br /> and I accept that risk. <br /> //�� n. ��' �/ ��/ . <br /> Signature � ' Dare <br /> � <br /> \.� -------- ----------- - --- --------_.�- -- <br />