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, � _ _ � <br /> . - , <br /> ' , <br /> i <br /> _ _ - ; <br /> � Backwater P�evention. Device Rebate::.Prog�am ' � i <br /> � ,Rebate Application.Forcn '.� � � <br /> �` ; ' i <br /> _ � �.;,;,, I <br /> �,�� ��� � <br /> PropertyOwnerName h%1 �• � ' <br /> Installation Address: �"� (l� �i�T U Y'(1!7 � ��" I <br /> Q���n ,, 'L /� , ' � <br /> City .(.4JC11.Y�1 State. �{�" Zip 'i"1��3 � <br /> . : . . . <br /> , . <br /> _:, . � ,,, ,: , . : �. ..- < � <br /> ' Maihng'rAcldress(�f diflerentJ .: ' �.;I' � <br /> ' ' ' I <br /> City ' ' • State. Zip <br /> �` p,' �, rQ�p ,�.,,,n <br /> .Email.: V�'L��V�,'Ou�O�v� • � ��LOYY � Ph'one �} UG��='��� � <br /> � � � �,': < �:: ; <br /> - Total Cost to Install Gewce (f�om contracfor mvo�ce): $� ` ?� S�Ys: ✓'J � <br /> ' 3 <br /> Please yerify the followmg. . ' <br /> ' [� I am the owner of the.propertywhere the backwater pre�ention device'was installed <br /> T . . . . , � . . � ' <br /> � I worked with�the`contractor to:determ�.ielthe locatwn for the backwater preyention device and <br /> understand thatthe deciswre�egarding the location of'the�device was m�ne:: ' I <br /> � My contractor instructed me how to access inspect and maintain the device. • ' <br /> � I und'erstand that I'am responsible formaintaining theibackwaterpreventwn.dewce and-keeping: ? ' <br /> ik:in good working:order„unless.it is installed'm lhe city nght;of-viay. : y <br /> - � ; " s <br /> �� (f I sell;my property,.Lwill rnake�potentlal buyers aware of the backwater pre4ention device and. ' - ' <br /> the need to mspectand'maintain:ihon a regularbasis ' 4 <br /> � i am enclosmg all of the necessary paperwork�(use tfie yellow Rebate Submittal Checklist) ` . � <br /> . <br /> . i <br /> SelecYfrom the following:. , ' <br /> � � � .. �. � � . ' �. �. _ i <br /> ❑ The wnlractor,identi6ed downspouts or.other drainage:llines.thet were connecled to my sewer, . ; <br /> line(belween my house and the installed device)and.removed;or rerouteddhern: � <br /> � To my knowledge, my propeRy has no downspouts or other drainage connected to my sewer line � <br /> ;betweenmy house and.the installed device) � <br /> � <br /> ❑ Tbere are downspouts orother.drainage lines connected lo my sewer line (between my house � <br /> and the inslalled,device);i.understand that leaving,these connections'creates a.risk of.ftooding,. ! <br /> , ' i <br /> and:l'accept that nsk. <br /> ' `. : ' : , � <br /> ; <br /> , ," � �t <br /> Signafure Date � ' J t <br /> _ I <br /> w , i <br /> . . , .. . . ' . , .,. . . 3 <br /> � ' . . � . . .. ' � <br /> • . - . , - �. , . � . .- . . . . � <br /> � <br /> i <br />