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j <br /> � <br /> �� Backwater Prevention Device Rebat�• Program � <br /> �w��... Rebate Appiication Form ` <br /> :.:3.�,. <br /> � <br /> - ---- ----- -- – --- __--_ — ___ I <br /> Property Owner Name Jb� � �� � <br /> Installation Address Z��Z Cei9-c� . S � � <br /> _ _ _ � <br /> � <br /> City �a�'�f/- -- —State' --Ld�? 7_ip--�,�'70/• I <br /> � <br /> Mailing Address (ildiNmm�f) �._��'���n� — ` <br /> � <br /> citv�,��c--// _ State (N_�__.Gip:_qf'io/—_ ; <br /> Finail I'hone (-/zy) 2�5_S?�1 � <br /> —-- � <br /> Tntal Cost to Install Device (/rorn .mnfraclo�mvoice) $,__z�y'�,.�____ � <br /> 1 <br /> I <br /> _.._—_ _ __ _ . _— _ __ ___—___ _ I <br /> Please verify fhe following: j <br /> (�I am the ownar of the property where the backwater prevention device was installed i <br /> ��worked with the conlraclor to delermine the location for the har.kwater prevenlion device and � <br /> nders�and thal the decision regardiny the IocaUon o(the device was mine. I <br /> � <br /> M�coniractor instructed me how to access, inspect, and mainlain the device � <br /> [L]�I linderstand that I am responSihle for mainlainm�lhn, backwaler preven6on device and keeping � <br /> it jh good working order, unless it is installed in the city righ6o(way ` <br /> ���I >ell my property, I will make potr.ntial buyers aware ot the backwater prevenlion device and i <br /> the eed to inspect and maintain it on a mgular basis 'i <br /> uI am enclosing all of ihe ner.essary paperwork (use the yellow Rebale Submillal Cfieckhsl) i I <br /> Select(rom the following: � <br /> �he coniractor identihed downspuuls or olhei draincige Ilines ihal were connecled to my sewer � <br /> Ime (be.tween my house and Ihr. installed device)ancl iemoved, a rernuled them � <br /> I <br /> ��o my knowledge, my properly hns no downspouls or other drainage cannected lo my sewer hne � <br /> 'S�T�h�,�Ween my house and the inslalled devlc�) <br /> (�iiere are Anwnspoids or other dramage lines connr,cted to my sewer line (between my house ' <br /> and the inslalled dr.vir.e) 1 unAerstand that leavinc� Ihr.sr, r.onneclions creates� nsk o(tloodmg i <br /> and I acr,ept Ihat ri.k � <br /> i, <br /> � i �` I <br /> Signntur � u <� �.� -:��'�" Date d�- ��- l) i <br /> �� � � <br /> I <br /> i <br /> I <br />