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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> — --- - -- --� . ---- � , <br /> � Property O�vner Nama �Z� L �J �, <br /> � 11 �� C�� cl �1 <br /> � p <br /> InstallationAddress. N - --U � <br /> City: �-`J}� Sta�e �� �- _Zip:_ U a-� � _ <br /> tilailing Address(if diilerenQ� S r1-�1'�� <br /> ICity: _ State: ----Zip' -- � <br /> 1 � <br /> Email c�1tz,'f�� G�C1 ''-- Phone: (� S �5� O�� � � <br /> Total Cost to Install Device (lrom conhactor invoice) 5_7 S OD UU <br /> I <br /> Please verify the tollowing: <br /> G� fz� �c��� �orvrx� �-� �wt-t.c� <br /> � �VUU�L. UTJ�I ] S ��U�nr� �-� Gi-" <br /> �am the owner ot the property�t�here lhe back�vater prevention device was installed. � <br /> '�� I��� <br /> "� I v�orked�vith lhe conlracror to determine the localion for ihe backvrater Prevention device and ��,,;,,bu !t <br /> undersland thal lhe decision regarding the location o(the device was mine. <br /> • � �L`^�I � <br /> 'Ji My contraclor instrucled me hovi to access, inspecl, and maintain Oie device. <br /> l�7 I understand Ihat I am responsible for maintaining lhe back�vater prevention device and keeping <br /> it in good �vorking order, unless it is instailed in the cily right-of-aay <br /> If I seti my property, I will make potenlial buyers aware of the back�valer prevention device and <br /> the need lo inspect and maintain it on a regular basis. <br /> J I am enclosing all of Ihe necessary papenvork (use the yellov� Rebate Submiltal Checklisl). <br /> Select from the following: <br /> j! The contraclor identi(ied downspouts or olher drainac�e Ilines that were connecled to my s�r�ver <br /> hne (beltveen my house and ihe installed device) and removed,or rerouted them <br /> �To ny knowledge, my propeAy has no drnvnspouls or other drainage connected lo my se�ver line <br /> (behveen my house and lhe installed device). <br /> LJ There are downspouts or olher drainage lines connecled lo rny sewer line (belween my house <br /> and the inslalled device). I understand that leaving these connections creates a risk of flooding <br /> and I accepl that nsk. <br /> Signatu�� �� ��1 Date }'�'T�-t�—��-�� <br /> r <br />