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. i <br /> E 7 <br /> � �ackwater Prevention �evice Rebate Prograrn ! <br /> Rebate Applicatior� FoRn <br /> � <br /> i <br /> Property0wnerName � � I�•r�,iie.R„�c� ��>c.��i'1.����� � <br /> J �^ � <br /> Installalion Address: � `� C> � `>s`���� (=,V{=, . <br /> City: �-v-Q�c' \ 1 State: L�1� Zip.' I K���� ? <br /> .�,� i <br /> � Malling Address(d dlllerenf): t!�il S ' � I�5 ,'_^,� f�.<<-- I <br /> ; <br /> Ciry, _�-1 n���.c��-v�� Slate:_C.,' A ZfP_`l �''J_.3 ; <br /> [mailt M C�.G�Mr � �����1'� �r -(G� Phone� (3�-) y35 3Ci.5-1_ � <br /> � <br /> Tolal Cosl to Install Device(Irom confracfor invofce): 5_ <br /> i <br /> Ploasc verify the followfng: i <br /> I am Oie owner of ihe property where ihe bachvaler prevenlion devir.e was inslalled. ' <br /> . � <br /> � I worked with the coMraclor lo delermine the location for lhe backwater prevention device and • <br /> ;understand[hal the decision rec�arding Ihe location of Ihe device was mine. � <br /> G`�� My coNraclor inslructed me how to access, inspect, and maintain the device. i <br /> , <br /> �I undersfand that I am responsible tor maintainine�the backwater prevenlion device and keeping ; <br /> ;/�i�m yood woiking order, unless il is installed in Ihe dty nght-of-way. % <br /> l I sell my property, I will make potenlial buyers awa�o of Ihe baclovater prevention device and ` <br /> the need to inspect and maintaln it on a regular basis. <br /> ��5 <br /> I am enciosing all of the necessary paperwork(use Ihe yellow Rebate Submiltal Checklisl) ' <br /> Scloct from thn following: . <br /> ��he coNractor identlfied downspouts or other drainage Ilines Ihal were connecled to n�y sewer � <br /> �h e (between my house and the insta�led devlcej and removed, or rcroufetl them. � <br /> o my knowled�e, my ptaperty has no downspouls or other drainage connected lo my sewer I�ne <br /> �� (between my house and Ihe inslalled device). <br /> ❑ Thare arc downspouts or other drainape fines connecled to my sewei 6ne (between my house � <br /> :�nd the installed devlce). I undeisWnd Ihat leaving Qiese connectlons crr.ales a risk of Ilondin� <br /> and 1 accept tl�at risk. . <br /> �/r-��_/� `s� 7^ ]- �UIS <br /> Siqna�ure-1 f ,Date <br /> �� / ; <br /> / / <br /> � <br /> , <br /> � <br />