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Backwater Prevention Device Rebate� Program <br /> Reba�e Application Form <br /> — ____ __,. _-- --- -- -- _ _ -- <br /> IPropeny Owner Name: l�L(��v�.��t—_�._ i, <br /> iInstallalionAddress'. _��� (_�J^�`��_ ����—_ <br /> � City: �j/LtP� _ State: _(/��_ _ Z'p�-- -/-"—�� <br /> I, Mailing Address (il diHei�nf): __ _ __ — <br /> City: State: Zip:---- -- -- <br /> Email: C, �Ll j'�'is' /t_��n�S����-r_ C�. _ Phone: (I�jJ?- 33 9 — %3o z <br /> Total Cost to Inslall Device (Irom confractorinvoice): S __ p��_i�n� <br /> I --- <br /> Pleasc verify the following: <br /> L I am lhe o�•+ner of lhe property where the,back�t�aler prevenlion device svas installed. <br /> l <br /> �'I �vorked with the contraclor lo determine the Iocation for lhe backv�aler prevenlion device and <br /> understand lhat the decision regarding the Iocation of the device�vas mine. <br /> ;:j���y contractor insirucled me horv lo access, inspect, and maintain tne device. <br /> i <br /> �j�nderstand that I am responsible for maintaining the backwatei prevention davice and keeping <br /> il in good working order, unl�ss it is installed in the city right-of-wt�y. <br /> r' If I seii my property, I will make polsntial b�yers aviare of the backwa[er prevention device and <br /> Ihe need lo inspecl and mainlain it on a regular basis. <br /> [�- I�am enr,losing all of ihe necess�ry papenvnrk (use the yello�v Rehale Suhmiltal Checklist). <br /> Select from the following: <br /> ❑ Thc contraclor identified downspouls or other drainage Ilines that�vere connected to my Ser+er <br /> hno (bclween my house and Ihe inslailed device) and removed, or rerouted �hem <br /> �]'To my knowledgc, my property has no dovmspouls or other drainage cannecled lo my sewer linc <br /> � l (bel�veen my housr, and the installod device). <br /> ❑ There are downspouls or olher drainage lines connected to my se�ver hne(between my house <br /> and lhe inslalled device). I understand that Ieaving these connections creales a nsk of floodmg <br /> and I accepl that risk. <br /> . ,� � <br /> Signature_ �.I��� � `���2��+, Date � �� <br /> ✓ <br />