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Baakwater Prsvention Device Rebate Program <br /> Re�aate A�plication Form <br /> p� Owner Name: ���`�' �/�,----� ' ""��'�� <br /> Yf.i r�cv � "�-- <br /> Inslallation Address: � ��� <br /> ;,;ry: f�.,; ,�-� _ <br /> State: 1,��Z'P'� b�°F��/ <br /> -� , _ � g�c� <br /> Mailing Address(if diHerenf):��� <br /> City: �7 <br /> ���� Staie lJ-� —Zip: / �y�s <br /> Email � �✓����� P f CA '1 Phone: (y2� �j� "l�'1-L <br /> ��1 � • 5� <br /> Tctal Cost lU Install Device (from conVaclor invoice); 5 - <br /> Please verify the following: <br /> � I am the owner oi ihe property wliere the trackwater prevention device was installed. <br /> Lx I worked with the contreclor to determine the location for ihe backwater prevention device aod <br /> understand that the decision regarding the location of the device was mine. <br /> 0 My contraclor instrucieJ me how to access, inspect, and maintain Ihe device. <br /> � I undersla.nd Ihat I am responsible fo: mainlaining the backwater prevention device and keeping <br /> il in good working order, unless it is installed in the ciry right•oi-way. <br /> Q I(1 sell my p�operty, 1 will r�ake potenlial buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> � I am enclosing all o(rhe necessary papnrwork(use the yellow Rebate Submittal Checktist). <br /> Select from the following: <br /> � I ne (belween my house and the�nstalled device)1andrelmovedaor rerou ednthem. t� my sewer <br /> (�. To my knowledge, my property has no downspouts or olher drainage connecled to my sewer line <br /> (behveen my house and the installed device). <br /> (�There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and the installed device). � understand that leaving ihese connections creales a risk ot f�ooding <br /> 2�d I accepl lhat risk. <br /> Signature <br /> �� Date �—�'- �O/S� <br />