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� Backwater Prevention Device Rebate Program <br /> � �w��,.. Rebate Application Forrn <br /> �..�,, <br /> � Property Owner Name �A.��'l G 0.. ___�1 . P� e-r 5,�� <br /> I�, Inslallation Addtess _2,`J.,'L_O �Q5'�11.tA,�'__�Y�e�f"_ _----- --- <br /> ' Cil�y _1��6-1��1.._'_'__. '- $�3�P.�. ._ yy � • . .-ZI�)� I�2� � <br /> � Mailing Address (d dMerenfJ� _ . ___ _ <br /> � City _--__ — Stale: . --Zip: <br /> Email: Yp�C�c� '�o�e_b 7@ Iv�S n .c.o��_ Phone (�2y�2'�i - 3A 7 u <br /> ' Totat Cast to Install Device (Irom confrar.for invoice): $ 2 � 9�4 6 6 <br /> _ _ _ _ —. l�� (-a �a y p t-a�n�;h� <br /> Plcase verify the (ollawing: <br /> o�yvtRv � Z8'"t4. F,6 1-v�n,�=� `` <br /> • � I am the owner of the properly�vhere tha backwaler prevention device was inslalled vt 34 7� <br /> � rj', 1�vorkr.d w�th the r.ontractor lo determine the locahon Inr the backwater prevenlion dewce and <br /> understand Ihat the decision regarding the locauon ol the device was mine. ��A�� ,�"„ <br /> �i� My contractor instructed me how to aceess,inspect, and maint, n�he devlce. �^ ��`� ��,,,.�.,�� <br /> !y,� I understand that I am respons�ble tor maintaining thr, backwater prevnnlion device and keeping ,��5/��- <br /> it in gond working order, unless it is installed in ihe city right-ol•way <br /> • � II I sell rny property, I will make potenbal buyers aware of the backwater prevenbon dewce and <br /> � lhe need to inspect and m�intain it on a mgular b�sis <br /> L I am enclosing all nf thi�necess�iry papenvnrk (use the yellrnv Reba,� ^ubmillal Checkhst) <br /> Select(rom the following: <br /> �The r.onlractor ideNihed duwnspnuls or other �lrainage Ilmes Ihat we�e connected lu my sewer <br /> , 6nc (beRveen my house and lhe inslalled device)and removed, or rerouted Ihem. <br /> (� Tn my knawledge, my property ha5-,n dnwnspouts or other dr�imge r.onner.leA ta my sewer Imr. <br /> (behvecn my house and Ihe ms�alb�d dewce). <br /> i <br /> ' ❑ T hrre are downspouts or other drainage Imes wnneded to my sewer hne (belween my hause <br /> and the mslalled device) I understand Ihal leaving �hese cunneclions creales a nsk ol lloodu�y <br /> and I accepl Ihat risk. <br /> I <br /> r �p <br /> S7gnature �1.LC[kiQ_l7l�h�-D� ---Date_ ,�, �d /S <br /> I <br />