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� Backwater P�evention Device Rebate Program <br />Rebate ApplicaHon Form <br />Propsrly Owner Name: ZA�, l�.7 B. � O<5 <br />Installallon Addross: � � c l �+i'� �- � ��P� • ` p _ <br />�^ . <br />Gty: G�)N�/L� Stale:��zip: F':2 Ol <br />lutailing Addrest (il diRerenq: <br />�y, State: Dp: <br />E,nsn: <br />Pkas� Jalfy lho follmvi�g: <br />P,,,�: ly� � 8- �26c7 <br />[�t� Ihe owner of Ihe propeAy where IAe baekrrelu pevenUon�devlce wes Irotelkd. <br />1 wo�ked rAth 1hs conirada to detsrtnlne the bcadon for Ihe beokwater p�evamion device and <br />�ndenlind thel Ne dedslon regerding Ihe beation ol Ne devioe was mme. <br />ooii0riclor InsWctsd me Aow ta acass, Insp�cl, prid m�intain l�s devin. <br />1 undaistand Mat I am responsibb for mafnb'viiny Ihe backwater prwnNon dsrfa and kNping <br />tt in good woAcu+g wde*, unbas k is instaAed in Me aty rqhtqf•war. <br />� my propeAy, I will rtwks pote��lial buysrs aware ol fhe baekNaler prsverrton deviw and <br />tlie nwd lo inspoct antl maintain il an : tegular DaSis. <br />i am endosing atl of IAe neoessary papenwrk (use tAe ysnow RsDate SuOmiaal Cneddist). <br />g�1e�t}�om th� lollowiny: <br />� TAe mntradm IdentKred downspoule a oU�er drainage Ifines Ihat were aonneded to my uwer <br />Xne (Dstween my house and 1A� MspMed tlevias) and remove0. or rerouted Mem. <br />(�o my krawlE4pe, my property has no downspouts ar oMer dralnage aonnected lo my sewer Ifne <br />(peMreen my house and the instalbd devlce)• <br />� There ve 0ownspouls ar other Orolnege Fnec conneaed to my sewer Ime (OeAwe� my Aouss <br />arM tho instated doviae) I undersland tAat kavirg tnese oonnsctions ueates a risk of Ilooding <br />aM 1 accepl that risk. <br />Slpn�f re ' ���T <br />