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i <br /> � <br /> I <br /> �� Backwater Prevention Device Rebate Program i <br /> �w��,., Rebate Application Form ° <br /> �._.. � --- � <br /> PropertyOwnerName.�IGl���j>> lf�llll�[GC�l�{��� /lG�1"P 'l-- � <br /> Instailation Address: /(�2�� �l�i 90 /�Vi! � <br /> ci�y: ��'VI�i't�I� _state�_{����ip: �/ J?� � ' <br /> i <br /> Mailing Address (ildiNerent)� j <br /> City: State: Zip: ` <br /> Finail: _Phone: ( ) � <br /> ✓ \'II � <br /> Tolal Cost to Install Device (!rom contractorinvoice): 3����d <br /> � <br /> � <br /> i <br /> Please verify thc following: � <br /> �'� 1 am the owner of Ihe property wtiere the backwater prevention device was installed. ; <br /> �I worked wilh the contractor to determine the Iocation for Ihe backwater prevention device and <br /> understand that Ihe decision regarding the location of Ihe device was mine. <br /> I)cl'My conlractor inslrucled me how to access, inspect, and maintain the device. , <br /> �✓` I understand that I am responsible(or maintaining the backwater prevenlion device and keeping � <br /> il in good working ordcr, unless il is inslalled in Ihe r.ity right-ot-way. ; <br /> �p. If I sell my p'aperty, I will make potenlial buyers aware of the backvealer prevenlion device and ! <br /> \ ;,�a need to inspect anA maintain it on a regular basis. � <br /> (l;f I am enclosing all of the necessary papenvork(use the yellow Reb�le Submitlal Checklisl). ! <br /> \ � <br /> Sclect irom tha lollowing: � <br /> t <br /> ��The coMrar,tor idenlified dovmspouls or other dramage Ilines Ihat were connecled lo my sev�er <br /> ' hne (between my house and thc installed device) and removed, or rcrouled thr,m. � <br /> i <br /> ❑ To my knowledgc, my property has no downspouls or olhcr drainagc cannected to my sewer line , <br /> (hetween my house and Ihe installed device) � <br /> I <br /> � TI .re are downspouts or other drainage Iines connected lo my sewer line (he�ween my house <br /> and Ihe installed device). I understand Ihat Icaving these conneclions creates n risk of flooding <br /> and I accept Ihat risk � <br /> � <br /> l �i : <br /> 1� j� ,I y'j�""- Date � Z �� '� � ' <br /> Signafure� (', � ' �� ,' i <br /> j' � <br /> � <br /> i <br />