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i <br /> I <br /> . , <br /> ��� Backwal;er Prevention Device Rebate Program � <br /> Rebate Application Form � <br /> � <br /> — - -- - — ---- -- -, ; <br /> /� ^ � <br /> � Property O�n �er Name 1��17((a!1�� F�U�'✓_+�_ — — I <br /> � InstallationAddress: Z3�� ���� •`"�c�_-- _- - � <br /> I <br /> I �ity.. [�EC'-F� Statr C�Vj 1ip' Z�/ _ _ _ <br /> �J�ailing Address (d diNerent):_ ____—. � <br /> � Cily Slate Z.i � <br /> � -- P'---- --- � <br /> ' � � titi'�+r� co,�4 3y�_ � 8 R 6 � � <br /> Email: I�AR��u[,�V#5� Phone: (Y1�)_�_ i � <br /> ! ------ I � <br /> Total Cost lo Install Device (lrom contrectorinvoice): $ �L1,3����_�_._ <br /> �-- -- --- — — --- - — --- ! <br /> Please verity the following: E <br /> �I am Uie owner of lhe property where the backwater prevention device was installed. ! <br /> i <br /> �] I worked wdh the contracbr lo determine the Incatian for fhe backwater prevention device and <br /> understand Ihat Ihe decislon regarding Ihe location of the device ivas mine. <br /> ��(dy coiAractor instructed me how lo access, inspect, and maintain the device. <br /> �I unders:and thal I am responsible (or maintaining the back�vater prevenlion devlce and keeping <br /> If in good working order, uNess d is ins�alled in the city right•of-way, <br /> ��If I sell my property, I will make polential buyers aware nf the backwaler prevention device and j <br /> the need ro inspect and maintain it on a regular basis i <br /> (�I am enclosing all o(Ihe necessary papenvnrk(use the yellow Rebate Submdtal Checklist). <br /> Select fro�n the tollowing: � <br /> (� The contractor identilied do�vnspouts or olher tlrainage Ilines lhal were conrmded lo my sewer 1 <br /> I�ne (br.Iwecn rr�y house and the installed devir.c) and removed, or rerouted them i <br /> �i'� To my knowledge, rny property has no dov+nspouts a olher drainage r.onnected to my sewer hne ; <br /> (beM•een my house and the installed device). ; <br /> � There are downspouts or other drain�ge lines r,onner.ted to my sewe� line (belween my house i <br /> and the installed device). I understand thal leaving these connections creates a risk of floodiny , <br /> anA I accepl Ihal risk. � <br /> i <br /> � i I <br /> i I <br /> � �� /S ' I� <br /> Signature <br /> ��" Dafe �Z � � � � <br /> � <br /> � I <br /> i I <br /> , � I <br />