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Backwater Prevention Device Rebate Program <br /> E„ Rebate Application Form <br /> —, <br /> Property Owner Name: N,'n�,-,� G e'/f P �}'r <br /> I, Installation Address: ���� l>e�7ne� ST <br /> �' Cily: Fvc�ie�-� Stale: L✓/� ZiP_�1:.b/ <br /> �viailing Address (if dilferent): <br /> City:__ State: Zip: <br /> Email: Phone� (�ri)�'7G Sr�i'F <br /> iTotal Cost to Install Device ((rom contracforinvoice): �_�r5�„yi.� _ i <br /> � -------- — ---- <br /> Please veri(y the following: <br /> [-�I m Ihe ovaner of the property���here the backi�:ater prevention device e;as instalied. <br /> r I �vorked with the contractor to determine the location for the back�vater prevention device and <br /> und rstand that the deci ion regarding the localion of the device v�as mine. <br /> �onMa�tz.� ��E'�rm��exf d� l.y on� (�acc�h�elo�nh�c�l� inS�iall : <br /> ilriy co ractor inslructed me hova to access, inspect, and maintain the device. <br /> ,_ I understand that I am responsible for maintaining the backwater prevenlion device and keeping <br /> d in ood"�vorking order, untess it is installed in the ciry riqhl•of•�vay. <br /> J/ IF 1 sell my property, I will make potentiai buyers au�, . � o,the backwater prevenlion device and <br /> the need lo inspect and maintain it on a regular basis. <br /> ?_ am enclosin;�all of Ihe necessary papenvork (use Ihe yello��� Rebate Submiltal Checklist). <br /> Select from llic following: <br /> n 7he conlraclor identihed downspouts or other drainage Ilines th�l tivere cannected to my sewer <br /> line(behvecn my house and the installed devicc)and removed,or rerouted them. <br /> �YTo my k owledge, my property has no do�vnspouls or other drainage connecled to my sewer line <br /> � (be��� my house and Ihe installed device). <br /> ��re are downspouts or other drainage lines connected to my seU:er line (�et�vFen my house <br /> and the inshlled device). I understand ihat leaviny these co�nections crea,es a risk of Oooding <br /> acd I accepl lhat risk. <br /> Signature_��� � _ Datc lZ��.%�1i!� <br />