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' Backwater Prevention Device Rebate Program <br /> � Rebate Application Form <br /> � <br /> � --- _ -- - - -- - -- � <br /> � PropertyOr+nerName: _ ,PoIJp�LD � A�-l3oR_(�N IJRI�H_51aiMA � <br /> � InstallationAddress. a�ooa GI1�ST�1UT .5T <br /> i <br /> i c�iy � vERE�T - s�ai� �F� z�p:__ 98ao1 , <br /> i <br /> h4ailingAddress (i/di/lerenl) SAM� __ ___ <br /> Clly' -- -- State - 7iP'-- - � <br /> Emall. 17�A►:FSUIMF��t=RoNi i£:x•�oM Phone: (�{a�- 3�5-5'1 �o__ <br /> Tolal Cosl to Install Uevice ((rom conlrar,for invoice): $_�i -UO� C� <br /> I <br /> Plcasc vcrify thc following: <br /> ` �I am lhe owner ol the property v,hrre Ihr, backwa;er preverninn devir.e�vas installed. <br /> ; �I worked �viUi the contraclor lo determine Ihe location for 4ie backwater prevention device and <br /> i understand that the deasion regarding Ihe location of the Aevir.e was mme. <br /> �'My conlraclor instruded rne ho�v to access, inspect,and maintain the device. <br /> i }�{'I understand thal I am responsible for maintaining the backwater prevention device and keeping <br /> il in good �ti'orking order, unless il i; inslalled ui Ihe city iiyld-of way. <br /> I <br /> I �'I(I sell my property, I evill rnake potential biryers a�uim nf the hackwater prevenlion dewce arid <br /> � the need to inspecl anA maintain it on a regufar basis <br /> � �" I am enGosiny all ol the necessary paperwork (use the yellow Rebate Submdtal Checklist�. <br /> I <br /> ' Select (rom the following: <br /> ' [J 7he coniractor iden6fed dotvnspoul, or ulher drainaye Ilines lhat were connec�ed to my sewer <br /> hne (between nry house and the insLdlecl duvir.e) and removed, nr reruuted Ihem <br /> � � To my kn�wledgr., my pioperty has no downspuuts or olher drainaqe connecled to my sewer line <br /> (betwemi my house and lhe inslalled dewce). <br /> �] Tl�c«� �uu downspouls or olher dr�inage lines uwnnc�ctc�d lo my sewer line (beN+een my houso <br /> � and Uu inslalled dovir.e). I understand�that leav!ng llwse cxmnec:tions creatas a risk of Oc�din� <br /> � anA 1 acc�p��hat risk. <br /> ! Signaturo �.2�-'e'�L(� A�aacZe�vnv.�_Date CJ� ICn �S I <br /> I <br /> i <br /> � � <br /> I <br /> i <br /> � <br />