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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> / � <br /> Property Owner Name:� � � � C!��/, Y L L G <br /> Installation Address: � � �� � 0�!� v ��_ <br /> City:�U Q Q�' (� �'f State:��_Zip; G] �� D/ <br /> r t ,�7 <br /> Mailing Address (i(dillerenf): _� �i l/ l cl�' � �� ( 0�� /T U�� S��c' ��3 "�lid <br /> City:�/✓� � � __y`��_ State: l4/ i4- z�p:� K.� y o <br /> EmaIC ���_L�� EN'f0/'�H07`�"10� I, Gl�M Phone: ('fa� ,�yy�-D y D K <br /> Total Cost to Install Device(frt�m conlraclor invoiceJ: 5 <br /> —� <br /> Please verify the following: <br /> � <br /> �(,}il am ihe ovaner oi ihe property v+here the backwater prevention device was instalied. <br /> Ly' I worked witi the contractor to determine the localion for ihe backwater prevenlion device and <br /> undersland that the decision regarding the location oF the device�vas mine. <br /> j�L�'My cuntractor instrucled me how to access, inspect, and maintain the device. <br /> [�understand that I am responsibie for mainlaining lhe backwater prevention device and kecping <br /> it in good working order, unless it is installed in thc city ric�ht-o(-�vay. <br /> [t]�sell my property, I will make potential buyers aware ot Ihe backwater prevention device and <br /> lhe need io inspect and maintain il on a regular basis. <br /> �m er.;.iosin�all of Ihe necessary papenvork(use lhc yellow Rebate SubmiHal Checklisi). ' <br /> Select f��m the foilowing: <br /> ❑ The ccatraclor identiiied downspouts or oUier drainage Ilines thal�vere connected to my sewer <br /> lirc(betoreen my house and the inslalied device)and removed, or rerouted them. <br /> �o my knowledge, my property has no dawnspouls or olher drainage conn�cted to my sev�er line <br /> (belween my house and the inslalled device). <br /> ❑ There are dotvnspouts or other dralnar�e lines connecled to my se�ver line (belvieen my house <br /> and Ihe instalted device). I understand that leaving lhese conneclions creates a risk uf floodin� <br /> and I accept lh�t rsk. <br /> Signature_lr�_'�_�� Date�S :� o�� � � <br /> L <br />