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, ! <br /> I <br /> � <br /> i <br /> Backwater Prevention Device Rebate Program � <br /> �^�j�„r,��" Rebate Application Form ! <br /> i <br /> .. ___ ___._ _ .____ _ . _ _ .__ . ._ .__. . . _. ._ . . _. __ . � <br /> Property Owner Name: i_ ci�.�-����'- I� �� I 1 .SC��� � <br /> � � <br /> �nstallation Address: -> >� � �- �-�L�(� ��'� � <br /> I <br /> i <br /> Ciry. � Jl'� C � '�" Slale: �^ } ��Zip C1 V 1.L7 I i <br /> Mai�ing Address(d diNeronl): � <br /> { <br /> Gry _ State _zip: j <br /> Emad.�_�ll�h4�� I! 3 L� �OfI�'lni�,('rx�\ Phonet (�IJS) ? � (�7 i � � <br /> �— i <br /> Tolal Cosl to Inslall Devlce(!rom conlmcfa�nvoicoJ: 3 `Z, 7`U`�'' I <br /> � <br /> Please varliy lhe following: ` <br /> [� I am ihe owner o(Ihe praperty where Ihe backwater prevenlion device was installed. <br /> � I worked wilh the coMraclor to detertnine the location for Ihe backwater prevenlion device^nd ; <br /> understand Ihat the decision regarding the lowtion of the device was mine. <br /> � My contraclor instructed me how to access, inspecl, and mainlain the device <br /> �� I understand lhat I am responsible lor malnlaining the 6ackwaler pravenlion device and keeping � <br /> il in good working order,unless il is instailed in ihe city ripM-o6way <br /> � If I sell my propeity,I will make polenlial buyers aware of the backwaler prevention device and � <br /> Ihe need to inspect and mainlain il on a regular basis , <br /> � I em enclosmg all of Ihe necussary paperwark(use ihe yellow Rebale Submitlal Checklisl). � <br /> Sol¢ct(rom the fol�awlnp: <br /> i <br /> � ] The wntraclor idenlified downspouts or other dramage Ilmes Ihel were ronnccted to my sewer � <br /> line(botween my housc and the installed device)and removed,or rcrouted them. <br /> �,�� Ta my knrnvledpe,my property has no dowospouk or other dralnage connecled lo my sevier line � <br /> ' (befween my house and Ihe mstalled devwe) j <br /> ❑ There are downspouls or olhor dramage Ilnes connected to my sewer hne(between my house � <br /> and Ihe mslalled device) I undersland that leaving Ihese connectmns creeles e risk of Oooding � <br /> and I eccepl thal risk. <br /> �) p <br /> Slgnofurer tl.iw ��/"JL �.___ =.�=.z_",_=—Daro �j� 3_ (c� ; <br /> — � <br /> i <br /> I <br />