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i <br /> ; <br /> � <br /> �,�}� Backwater Prevention Device Rebate Program <br /> �'��E.,T Rebate Application Form I <br /> w - _ . <br /> �.� - <br /> Properly Owrer Name: ��/C� / ��-�-� � ��C � <br /> -7 /y � <br /> Insfallation Ac:dress: /`�� 7� ��"i�iv /7 �(� k <br /> City. f�il�✓���� Stale: 11�/� Zip: �gaG � � <br /> � <br /> �lalling Address(if dillerentJ: �.�/✓/� � <br /> _ <br /> City: State Zip._ _ <br /> Email: Phone: ( ) i <br /> � Tctal Cosl to Install Devic= (/�om conbactor invoiceJ: 5 S�l �`'� �� ' S I I l <br /> I ' � <br /> Please verify the following: i <br /> �am the o�.�ner of Ihe property where ihe back�valer prevention device was inslalled 1 <br /> �e:orked wilh Ihe conlractor;o determine the location(or tho b�:k�•�ater prevention device and <br /> und=rstand that the decision regarding the locallon of the device was mine N�.� i <br /> �Vi, INS'7iC'aCTia✓�✓91 L�vc � <br /> Po1y coniraclor instructed me how to access,ins;�ect, and mainlain the devic S �✓� ��v� /� /�I�yJQL <br /> � �r wHie:� r .e�4��� <br /> understand that I am responsibte for maiNaining the backwater prevention d�vice and keeping <br /> it n good tvorking order, unless i�is installed in Ihe city right-of-v+ay. <br /> i <br /> If I sell my property, I will make potenlial buyers av�are of the backe�aler prevention device and <br /> Ihc need to inspect and mainlaln i!on a regular hasis. <br /> �am enclosing all af the necessary papenvark(use Ihe yellow Rebate Submillal Checklist). I <br /> Selecl from Ihc tollowing: � <br /> t <br /> [L�The contractor idenhfied downspouls or other dralnage Ilines Ihal were connecled to my Sewer . <br /> line(bclween my house and Ihe installed device) ard ren•�oved, or rerouted lhem � <br /> [j To my knowledge, my property has no downspouts or other drainage connecfed lo my sewer line ' <br /> (beM1veen my house and Ihe inslalled device). <br /> (] There are do�a�nspouts or other drainage lines connecled to m�sewer line(behveen my house <br /> and the inslalled devlce). I understand that leaving ihese conneclions creates a risk o(flooding <br /> and I accept thal risk. <br /> �7 � ' <br /> Slgnature �l� �/I"� � I . 1 - �� - �S � <br /> �—�--�✓ Dafe <br />