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Backwater Prevention Device Rebate Program � <br /> Rebate Application Form ; <br /> n -- — � <br /> Property Owner Name: �,_ .�K��FD PI� I <br /> Installalion Address: _��� I �illfSl_�nli1� �j _ ___ I <br /> CitY: ��/�q��.- Slate: �_2ip:��_ ! <br /> �/ f <br /> Mailing Address (ildlflerenf): _�����J(oJ � <br /> Cify: G✓ . ( ---,— Stale:��--Zip: � � _ <br /> /� � t <br /> Finail: __ --_ --------Phone: 1�{.Z�1��0�-1J_ � <br /> t <br /> Tolal Cost lo Install Dovice (Irom r.onfrncforinvoir,e) $._ __ __ , _ ; <br /> i <br /> -- ------- --- ----- -- – -- — -- ' <br /> i <br /> Please verity the following: � <br /> I <br /> ,� I am IhQ owner of the property whem the backwater provention device was installed. i <br /> �I�vorked wilh .ne conlroclor to determine lhe loce6on lor the backwater prevention device and � <br /> understand Ihat Ihe docision rr.garding the localion of Ihe device was mine. � <br /> �My coniractur inslrucled me how to acc�. , infipect, and maintain Ihe device. <br /> �( I underetand Ihat I am responsible for mainlairnng lho backwator prevenlion devlce and keeping � <br /> it in good working order, unless it is installed in the cdy right-ol-v+ay. � <br /> �If I sell my property, I will make potontial buyeis aware of Ihe backwater prevention device and j <br /> Ihe need to inspecl and maiNain rt on a reyulm basis. � <br /> � I am enr.losing all ol the ner,ess�ry paperwork (use the yellow Rebale Sut�mlllal Cher,klisq <br /> Sclect irom thc follawing: <br /> [� Thie r.onlrartor ldentified downspouls or nlher dr�ina�n Ilines Ih:�t were connectad b my sewer i I <br /> Ime (betv�ecn my housc and Uie in:laned device)FUW remuvr.d, nr rcruuted �hem. � <br /> (�jT�To my knowlodge, my properiy has no downspouts or nther drainane r,onner.led to my sewer linc I <br /> r— (between my house nnd the installed d�vir.e) <br /> n Therr are downspouls or olher dralnaye I�nes connected tu my sewer hne(belween my house � <br /> and the installed device). I widerstand that Ir.avinq Ih��se conner,linns r.realeF a risk of flooding <br /> and I accepl thal nsk. � <br /> � <br /> i <br /> Sl�nafure. �Q� �� ' � U Aate_�.�--- I I <br /> i <br /> I <br /> � <br /> I � <br /> � <br />