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i <br /> I <br /> � <br /> 4 <br /> I <br /> ����'�"' Backwater Prevention f)evice Rebate Program ! <br /> Rebate Application Fo�m ' <br /> — � <br /> Pro ert Ownr.r Name: I <br /> P Y ��� �U I4.�•{" � <br /> Inslallation Address:�_� � <br /> City' `Js, l?--2)l e�� _Slale: Zip: �� `� �� � <br /> 1�� <br /> Mailing Address(ifdrllerent):Y�� �, �� '[�,�� ��g.��_ l�'��- I <br /> I <br /> c�ry:�E,c�_vn.o�.�S S1ale: � �' _Zip: ('1•SS C'�7�So � <br /> FinaiL � I T�� yy�4=.�_��Mtn.-tiD.�,�P�one:(�tSj `i`7l - ���K� � <br /> i <br /> Total Cost to Inslall Device(!rom conlractorrnvoice):$ ! <br /> Please verify the following: ' <br /> � I am Ihe owner of the property where the back�valer prevention device was inslalled. ; <br /> I worked with the contractor lo delermine ihe location for Ihe backwaler prevention device and <br /> undersland Ihal Ihe decision regarding Qie localion of Ihe device was mine. <br /> F�i My conlraclor instrucled me how to aecess,inspecl, and maintain Ihe device. <br /> .�.� ; <br /> �] I undersland Ihal I am responsible for mainlaininy the backwaler pn:vention devire and keeping <br /> il in good working order, unless it is inslalled in ihe city righl-o4way. <br /> �� If I sell my prop�rty, I will make potenlial buyers aware of ihe backwaler prevention device and <br /> the need lo inspecl and mainiain it on a reyular basis. <br /> •�/I I am enclosiny all of lhe necessary paperwork(use Ihe yellow Rebate Suhmiltal Checklist). � <br /> �` <br /> Scloct Irom iho following: <br /> , <br /> �.. I he contractor idenlilied downspouls or nlher drainage Ilines Ihat v�ere connecled 10 my sewer � <br /> line(betwe.en my house and the installed device)and removed,or rerouled them. � <br /> ❑ To my knowledgc, my property has no downspouls or other drainage connecied to my sewer linc <br /> (hetween my house and the installed device). <br /> (] There are downspouls or olher drainage lines conneGed to nry se�vcr line(belwcen nry house <br /> and Ihe instailed device). I understand that leaviny Ihese cnnnections ueales a risk of floodin� <br /> and I accepl Ihat risk. ' <br /> (n�°� �--� � .^� , ' I � � <br /> SignaWre `_.`-�� t__- 1 �^—'� �-�-^�Datc �P\ �G �� + <br /> � <br /> i <br /> l <br /> i <br /> � <br />