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, <br /> ± /� Backwater Prevention De�ice Rebate Program <br /> ����,�,,. Rebate Application Form <br /> �i <br /> Property Owner Name:�_p�'d�"^— <br /> InstallationAddress: 21 O �j �DL-��-i'�_/��—� <br /> City: �1/�Pc�-?�'1 State: l.Jiq Zip / �' 'j,� � <br /> Mailing Address (ifdil(erenQ:�0���>� ��-��� �.v�/ �� r <br /> �r- <br /> City: �c �Cgt4.Wu.V�c State: �[,/cc.- Zip:�,��J � <br /> Email:��i�_ 0�$o� '?C7� fii:�1uf-��L.N^Phone:�)Z��" �f j l�._ -�/ <br /> —,`- �r <br /> Total Cost to Install Device(lrom contrector invoice): S �DO p� <br /> Please verify the foilowing: <br /> � I am the owner of the property where the backwater prevention device was installed. <br /> '� I worked with the contractor lo determine the location for ihe backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> � My contractor instructed me how to access, inspect, and mainlain lhe device. <br /> �I understand that I am responsible for maintaining the backvaater prevention device and keeping <br /> it in good working order, unless it is instalted in the city righ4of-way. <br /> L�q If I sell my property, I wili make polenliai buyers aware of the backwaler prevention device and <br /> � "the need to inspect and maintain it on a regular basis. <br /> �I am enclosing all of the necessary papenvork(use the yellow Rebate Submittal Checklistj. <br /> Select from the following: <br /> ❑ The contractor identified downspouls or other drainage Ilines that were connected lo my sewer <br /> line (between my house and the installad device)and removed, or rerouted them. <br /> To my knowledge, my property has no downspouts or olher drainage connected to my sewer line <br /> (behveen my house and the installed device). I, <br /> ❑ There are downspouls or other drainage lines connected lo my sewer line(between my house ! I <br /> and the inslalled device). I understand that leaving these connections creates a risk of tlooding <br /> and 1 accept that risk. <br /> ���/,� I <br /> Signafure /'"' � Date I � <br /> . . . .. . ..__ ..._ _. i <br />