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/^��� Backwater Prevention Device Rebate Program <br /> � Q, Rebate Application Form <br /> -- - -- - - <br /> � — � - �� : t � � <br /> r rcPcrty Ow�er Namn _`l-.��1--.1�.���h���'+'�.%'�_I.l��-- - ----- <br /> � <br /> � � � C' <br /> Inslalla!ronAddress ,�����<�. �,�1_ l{ ll \'�� I <br /> Cly.���� _��.«.-l-ti�-Slate _.��� •.�_ _ 7iP ���`��1C1�1-- ----- I <br /> I � '�/ i r � I <br /> _ ��.�1�_ 1�1 - ' �r, � - <br /> ; 6:'�� �r�� Addiess pf drNermf) l" �_ — . ,� --_ i <br /> i . <br /> I <br /> � ��1.. '.t�� u��LZ� �� �,�3 __ z,� �1�-;C����� --- � <br /> C I�� ( � S�atc <br /> �I F inail it .1 ����.�'`('.�A�(L�_LL�i.)c.�L�'�'�ore (I���;_� C f ���,'' I� <br /> � <br /> � I <br /> To!a!Cosl to Irslali Dev�r.A (bnm co�f�atfm invoice) S— _--_ - -._._ . . .__ _ i <br /> i <br /> I. - --- �� - -- - - -� ----� ------ ----- - - - -�- - - I <br /> Plcase verily Ihe(ollowing: <br /> i�,, �am the owner ol lhe properry where the bar.kweter preventinn device was instanrd <br /> i j I w�rketl with the r.ont�actor to aeterm�ne!he loca6on for Ihe backwater prever:�on ae�ne.e.���d <br /> undr.rslanA Ihal L�c tleds'on regardmg Ihe lor.at�n�ol Ihe devire was rn��e <br /> �l' 1;y wntra�lor inslrudeel me hnw lo access.insner,t, �nd maintain Ihe tlev�ce <br /> �--i' I undrr:�Aand Iha!I am rr�pnnaihle lor mainLvmng Ihr harMv+airr prevenhon dnv.rr?�v1 4rrpu•�� <br /> ` d in�oad v.�orking o�der, unless 4 is installed ui Ihe cRy iiyhl�ol•v:ay <br /> ��j� If I scll Ty proprdy, I wdl mnke polenhnl buycrs awa�e ol the har.kwaler preveMion dec��o-an�f <br /> Ihc�m.�d lo i�specl a�d main!,nn d on a regular has�s <br /> �.)� I a�n ercios�.np a'�i ol Ihe ner.escary paperv�ork (use ihe ycllovr Rebate Submrtta! ChecKl sq <br /> Selecl lram the inllowing: <br /> ., Tlir rn!ti�mlor iAeid hed downspoids nr Mhr.r d�.un;iye IPnes ihal were co��nected�o my eer:e� <br /> I•ie(betv:cen m�-hou;e and P�e uislaPed dev�rr)and remnveA,nr rerouted them <br /> ! � Tu my knowledge, my p�opeqy has no down,pouls or othc�dia naye connedeA to my sc�+�� � lu�r <br /> (Le!wre�i iny hnuse am�l Ihe int,ta�!ed dev��ce) <br /> �� I I�vrr��•n dnv,r5pouls ui other d•ainayF'�c+rs cmric�:ted lo nry sNwer Ime (behveen my h;iuti�-: <br /> .v��.l Ihu �nt�all�d drvicr) I WltlCrslanA ih;i�lodving Ihvsr cnnnnrlinnt i.irai���,o riti!nt�londir 7 <br /> :md I :1��.opl Ih:1;ntk <br /> �, �t . � '� � i <br /> �� �._ � i`) :� ���.�_1--� -- Datc —.�_ �.t :v� .. i_ � . <br /> Signafwr. _'..�� . � - <br />