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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> ,-- —_ - ------ <br /> � Property Owner Name: _J_��`�?t' r� r • `�Q-`�`r�. e�� <br /> Installation Address. Z-`� � 5 �e��r _ ��' __ __ _ <br /> Cil � `l Il t'Q.[� SIatC l.-) p- Zi � �v 2D 1 <br /> y -- ------ - — P: <br /> IMailing Address (il diNerenq: _____ _ _ _ <br /> I Cily -----------_- State: -- - Zip — <br /> Email: .ols��_�'lo�.se4��n__,tiCn,s� _n_e,f_ ___ Phone (y�s) _��9-Z_-t�'� <br /> Total Cost to Install Device (lrom confraclor invoir,e) 5 0�`{��� p �__ __ __ ____ <br /> � <br /> I------ __ —_ _— -- -- -- - - <br /> Please verify the followfng: <br /> �i I am the ovmer ol the propeRy where the back�vater prevenlion device�vas installed. <br /> [f I worked wdh lhe conlraGor to delermine the location lor the backwaler prevention device and <br /> understand Ihat th�,decision regarding the IocaGon of the device was mine <br /> �My contraclor instructed me how to access, inspect, and maintain the device. <br /> �understand that I am responsible for mainlaining the backwaler prevention device and keeping <br /> il m good tivorkmg order, unlcss it is installed in lhe cily nght-ol-way. <br /> [�I(I sell my prnperty, I will make polential buyers aware ol the backwaler prevenlion device and <br /> Ihe neod to inspect and mainlain it on a regular Uasis. <br /> �I am enclosing all ot ihe necessary paperwoik (usr. thr. yr.11ow Rebale SUI7f111IIflI CIIP.f,I(IISI) <br /> Select from the Tollowing: <br /> ( � The coniraclor idenlilied downspouts or other dralnage Ihnes lhal were cunn�ct��d to nry sewer <br /> bne (betwer.n my housr. and thr, installed device) and remnveA, or reroutPd th��^i <br /> �"�To my knowledye, my property has no downspouls or othcr drainagc conn��� ;u my sewer bne <br /> (hetwecn my house and the installed devir.c) <br /> LJ There are Aownspnuts or alher drainage lines connecled to my sewer hne (helween my hous� <br /> and Ihe installed device) I understand thal leaving these con�ections r.reat�s a risk ol 0ooding <br /> and I ar.cept Ihal risk <br /> Signatur��__ i�/t!o`��- Dafe 9' ZU� <br />