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- -- ---- ,_ _._ �. _ �_ --- - —._ . . _. _._ . _ . _ --- --.. . _� - ----- <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> _ _____ ----- -- ---- ---- - <br /> Property Owner Name: Yal � ��{."I�_�_____ <br /> Installation Address: a'� � � C���1� � ' — <br /> City: ��______ State: �q __2ip �' � �� � <br /> MailingAddress(ildiHerontJ: �O_ p���_/�Ll.C- . ��� PIh-f S'7'��[9' <br /> Cily: -��----__--- State ��--- Z�P'.—_(_U�J <br /> E�nail: __ ____—_ Phone: (�� J2_�q�3� 3 <br /> Total Cost to Install Device (Irom confractor invoice): $ __ ____._. <br /> — ------ <br /> Please veri(y lhe following: <br /> � I am the owner of Ihe property where the backwater prevention device was installed. <br /> � I worked with the contraclor lo delermine ihe location for lhe backwater preventlon device and <br /> understand that the decision regarding Ihe location of the device was mine. <br /> � My contraclor inshucled me hnw to access, inspect, and mainlain lhe device. <br /> I understand lhal I am responsible lor mainlaining the backwater prevention device and keeping <br /> il in good workinc� order, unless it is installed in lhe city right•of-way. <br /> � If I sell my property, I will make potential buyers aware ol the backwaler prevention device and <br /> thc need to inspecl and maintain it on a regular basis. <br /> � I am enclosing all of Ihe necessary papc�rwork(use ihe yellow Robate Submitlal Checklist). <br /> Gbi�L,�,.�c�� ��S t�C�os'6 V �'� °� w�v;c <br /> Select irom t c�(o lowing: <br /> ❑ The contraclor identdied downspouls or olher drainage Ilines that were connected�o nry sewer <br /> line (between my house and lhe inslalled devicc) and removed, or rerouted them. <br /> �l To my knowledgo, my proporty has no downspoids or other drainage connncled lo my sewer line <br /> � (between my house and lhe inslalled device). <br /> [_] There are downspouls or olher drainage lines connected lo my sewer line (between my house <br /> and the inslalled device). I understand ihal leaving these c:onnections creates a risk ol Ilooding <br /> and I accept that risk <br /> Signature_`���2f/ --- --Dafe ��� (-�___ <br /> __�l��T <br />