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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> ...; <br /> Property Owner Neme:_ r� „ � d- TAvr�� �mb __ <br /> Installation Address: �g24� Cl�a� f't' • <br /> Gly: ��/onr.4�- State: I.vq 2ip: y�2 1 — <br /> , <br /> ( Mailing Address(!I dil/erenf): �.*�-L <br /> ��ty; State: Zip: <br /> Email: 3 .m(ou.l�V�a�� . Gvm _ _ Phone:(yts� .�'i9 -f3Q7B <br /> Total Cost to Inatall Devioe(from contracfor/nvolce):S <br /> Plas�verify ths following: <br /> �I,am the ownar of Ihe properly where the backwater preyention devke was�Instailed. <br /> � I worked with ihe conlractor lo determine the Iocetion for the backwater prevention device and <br /> understand thal the deGslon rega�ding the loration ol the device.was mine. <br /> �My contractor instructed ma how to access.Inspect,end maintaln the device. <br /> �I.understand lhat I am responslble for maintaining lhe backwater preventlon device end'keeping <br /> it in pood working order, unless R is installed In the clty right•of-way. <br /> � If 1 sell my propeAy, I wlll meke potential buyera aware of Ihe backwater preventlon device and <br /> lhe need to Inspect and maintain It on e repular basis. <br /> �I am enGosing all of the necessary paperwork(use the yellow Rebate Submiqal Chedclisg. <br /> Select hom th�followinp: <br /> ❑ The conlrador ldentified downspouls or other drainage�llines that were connected to my sewer <br /> Iine(between my house end,tha inslelled device)and removed„nr rerouted ihem. <br /> � To my knowledge, my property has no downspouts er other dralnage con�ected to my sewer Iine <br /> (befween my houae end the inatalled device). <br /> ❑ There are downspouts or olher drainaye Ilnes conneded to my sewer Iine (between my house <br /> and the inatelled device). I undersland Ihal leaving Ihese connecllons creates a riak ot 800ding <br /> and I eccept that risk. <br /> Slpnatu►e,��on,.. n,c�ltil � Date ��-l�f-(�F <br />