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i <br /> � Backwater Prevention Device Rebate Program ; <br /> Rebate Appiication Form � <br /> �, <br /> Properiy Owner Name: tOA✓YQ����iYlR�'�'- j <br /> Installal'an Address: � 7_ ?_�% �e i <br /> Cily: EV��t n SWte: W/� Z�p 7AZO/ � <br /> MailingAddress(ildll/erenlJ: �5 �03 O�'�rCrte�kP/�wii t#/of � <br /> �ity: /�Pc(r.�or�� State: W� z�P 9�0.�z <br /> Email: ��'7�iI��90vIc�G�l��of�C. Lo✓N Phone (y21(�L�7�J� <br /> Total Cost to Insta�l Device(Irom confracforinvoice):5 2���kg • <br /> Please vetify Ihe following: ' <br /> i <br /> �I am the owner of the property where Ihe backwater prevenlion device was ins1a11ed. � <br /> � t worked with Ihe conlractor lo delermine the lowtian�or the backwater preventlon device and ' <br /> undersland Ihat lha deasion regarding the lowtion of the device was mine. � <br /> Is�c' �dy conlraalor insWcted mo how lo access,InspecC and mainlain Ihe device. <br /> ��, <br /> � 1 undersland lhat I am rasponsible lor maintaining the back�vater prevention device and keeping � <br /> il in gaod working order, unless It is installed in the cily nghl-obway. ; <br /> � If t sell my property, I wi�l make polenlial buyers aware ot the backwaler prevention device and ! <br /> Ihe need to inspecl and mainlain il on a regular basis. <br /> �1 am enciosing all o(Ihe necessary papenvork(use Ihe yeilow Rebate Submlllal Checklisq. � <br /> Sclect Irom the following: i <br /> ❑ The contractor idenllfied downspouls or olher drainage Iiines that were connecled lo my sewer � <br /> line(behveen my house and lhe insla�led device)and removed,or rerouted them. j <br /> i <br /> ❑ To my knowtedge,my property has�o downspouls or other drainage connecled to my sewer line <br /> (hetween my house and Ihe inslalled device). ; <br /> � There are downypouls or other drainage lines connecled lo my,ew�r tine(beiween my house i <br /> and lhe mslalled device). I undersland lhal leaving Ihese connections creatos a risk of Ilooding <br /> and I ac�ept that dsk. <br /> i <br /> • . " � i <br /> Slgnaturc_;��/ �� Dafe � �� �-� ' <br /> _ �- � <br /> I <br /> , <br />