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i <br /> ; <br /> � <br /> � <br /> Rackwater Prev�ntiorl Device Rebate Proyram ; <br /> � Rebate Application Form � <br /> i <br /> � <br /> ) � <br /> ProportyownerName: A��N , EI..�E7E�5o� <br /> I <br /> Installalion Addreu: � �� 0 !.8�1 i <br /> � �� qg�.oc - l6ao � <br /> cny: �VE1fE�7-�- sre�e� zip� . <br /> 1 <br /> Maifing Add2ss(U tlilferenfJ: ! <br /> r <br /> r.iry: State: Zip: i <br /> i <br /> Emall: ,_ Phone:( ) ' <br /> I <br /> i <br /> Totai Cost to Install Device(fiam contractorinvolce):5 � <br /> i <br /> Please veriiy the following: I <br /> � I am the owner oi the property tvhere tho backtivater prevenfion eevice wes installed. � <br /> t <br /> � I worked wfth the conlractor to determine the locatlon for the backwator prevenUon device end i <br /> ' understand that the decision regaMing Ihe toc2tion oF the device was mine. � <br /> �My contractor Instructed me how to access,tnspect,end mainlain the deviee. I <br /> �JI untlerstanC lhal I am tesponsible for maintaining the haclnYater proventlon device and kecping � <br /> ` ' it in good working order, unless it Is instalied in the city right-of-way. ; <br /> �YI If I selt my property,I will make potential buyers aware of(I�C backwater preventi�n device and '; <br /> �` the need ro Inspect and malnteln it on a regular bAsis. � <br /> [] I am enclvsing all of fhe necessary paperwortc(u9e ihe yetlow Rebafe 3ubmittal Checkiisl), i <br /> j <br /> Select tr+om the following: �I <br /> ❑ The conl�actor idenii�ed dawnspouls or other drainage Ilines thal werL connected to my sewer ' <br /> line(between my house and the instalied device)and removed,or rerouted them, � <br /> �j To my knowledge,my property has no downspouts or othet drainage ccnneCied to my sewer Ilne 1 <br /> ' �(6ehveen my house and Ihe installed dovice). i <br /> ❑ Them are downspouts or other drainage lines connectea to my sewer line(beAveen my house � <br /> and the inslalied device). I understAnd Ihat Ieeving these wnnec6ons creates a rfsk ot poodi(tg I <br /> and 1 accept lhat risk. ! <br /> I <br /> t <br /> i <br /> Signatu ate � � 1� � <br /> I <br /> i <br /> i <br />