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�j Backwater Prevention Device Rebate Program <br /> ^�— Rebate Application Form <br /> M.�y�ci i <br /> \� <br /> Property Ov:ner Name:_���� `��tV'eH <br /> — /� — —T --- <br /> Installation Address _ __�«-C� ����C ��-�, __ <br /> City:�VZ'VC�L� Slate: LJ Ps Zip: � �ZU ( <br /> R7alling Address(iI dilferent): S �""1� __ _ __ <br /> � City: _ State: Zip: I <br /> I [mail: Y�"'t"�'��OIo � ��-' �FYti�.'��c� .�(M1 Phone:(��L�j _i�(a`( - S 33U I <br /> ITo'�I Cost to Install Device(`rom confraclor invoice): S ZZf1 -F'"�'��:,� <br /> � _�Y9f, s9 j <br /> Please verify the following: <br /> � I am the o�vner ot the property where fhe baclnvater prevenlion device�vas installed. <br /> � I v:orked with ihe coNrador to determine the location for lhe backwater prevention dovice and <br /> understand that the decision regardmg lhe location of Ihe devir.e v�as mine. <br /> (� tviy contractor instructed me how to access, inspect, and mainlain the device. <br /> [� I understand Ihat I am responsible(or mainlaining ihe backwater prevenlion device and keeping <br /> it in good working ordcr, unless it is installed in ihe ciry right•of-�vay. <br /> � If I sell my property, I will make polenlial buyers awaro c(lhe backwaler prevenlion device and <br /> the necd to inspect.md maintain it on a regular basis. <br /> U I am enclosing all ol Ihe necessary papenvork(use the yellow Rebale Subrniltal Checklist). <br /> Select from the following: <br /> �_� The eontraclur identified downspouls or other drainage Ilines �hat were connected lo m� se�•�er <br /> line(behveen my house and thc inslalled dovice)and removed, or reroulod Ihem. <br /> � To my knor�ledgq my property has no downspouts or other drainage connected to my se�ver Ime <br /> (beh•�een my houso and the inslatled device). <br /> ❑ Thero are downspouls or alher drainage Iines connecled to my sewcr line(between my housc <br /> and the installed device). I understand thal leaving these conneclions creates a risk o(Ooodinc� <br /> and I accep!Ihat risk. <br /> �,,�.��y{ / � 1r <br /> Signa(urc��^/�/ °"� C%� Date�Z�J /� <br />