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� —.- —„�' li <br /> I . <br /> � Backwater Prevention Device Rebate Program <br /> , Rebate Application Form <br /> I�— �.L ,, p`.,' <br /> Property Ormer Nama: _ _��� -` ��(�_ � � <br /> Installalion Address: �'� ' •lv` � �Z� <br /> —�1-- �o O_� <br /> Cily: '"w ��'�� Slate: a.- Zip: <br /> Alailin�i�ddress (iI diHerentJ: <br /> Ciry: �_ � State��_�2�:--/��� <br /> Emai�: .Seb�� ��,o d�I I�Q�'��1r.�`^Ph�e`c`'�2,.>'-zs�2`T I I <br /> bJ <br /> Total Cost to Inslall Device (fiom confractor invoice)� 5 2�5�b <br /> Please verify the following: <br /> ¢� I am Ihe owner of the property where the backwater prevention device was instal'ed. <br /> � I worked with the conlrador to determine lhe location for ihe backwater prevenlion device and <br /> understand lhal the decision re�arding the IocaGon of�he device was mine. <br /> My contractor instructed me ho�v to access, inspecl, and maintain the device. <br /> � I undersland that I am responsihle for maintaining the backwater prevention dee'ice and keeping <br /> it in good working order, unless it is installed in the city nght•ol-way. <br /> `� If I sell my property, I wiil make polenliol buyers aware of lhe beckwater prevention device and <br /> the need to inspecl and mainlain il on a regular basis. <br /> '�_ I am miclosiny all of the necessary paperwork(use the yellow Rebate Submiltal Checklisl). <br /> Select trom the following: <br /> �Tlie contractor iAr.ntified downspouts or other draina�e Ilines that were connecled to my sewer <br /> line (behveen my housc and lhe installed device)and removed, or rerouted lhem. <br /> '{�. To rny knowledge, my prnperty has no downspnuts or other dr�inaye c onnecled to my sewer line <br /> � �belwecn my housc and thr, inslalled devicc). <br /> (t�jThere are downspouts ar other drainage lines r.onnected lo my sewer Iine (between my house <br /> �� and lhe inslalled device). I underetand thal leavin�these cornieclions creales a risk o(Oooding <br /> and I accep[lhal risk. <br /> Signature--=``�E=�...�ll��-�.���,.=-LDate '" v <br /> � \ <br />