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Backwater Prevention Device Rebate Program <br />Rebate rApplicatfon Form : <br />Property Owner Neme: K' chw-�, ►�YDn S <br />Installatlon Address: ^� � � � ('��\ •f-� J � <br />Cfty: �V Q�^a� Sfete: _li',%A L'p: � 2�G I•. <br />Meiling Address (X dr7feren7): P� B� S) � <br />cicy: Sre�iti �.Ir.: � s�re: �.✓�A— vP: �� '06'a <br />Email: L7r PM ��.a" �4�; N+�� Phone: Q[�) �� 1^�'1 �,� <br />Totel Cost to Install Devlu (lrom Confrectorinvo(cgJ: $�T �a� _�(�� •'%'2�a�'� ' o <br />Plosao vart►y the folbwing: <br />'�J I em the owner ot the property where tha backweler preven6on dwice wes Insbilled. ". <br />� warked with the conVador lo determine the locatlon Por the beckweter preven6on device and <br />u erstand thet the dedslon reparding the Iocation af the device was mine. <br />Mty contractor instructed me how to aooese, Inspecl, end melntein the device. �. <br />�understand thet I am reeponsfble for meinlalnf�g Ihe ba�kwaler p�eventlon device end keeping <br />it i� good working order, unless it Is instolled In the city right-ot•way. <br />I�j' fl I eell my propetty, 1 wtll make potentlel buyera aware of the backwater preventlon device end <br />th need to Inepect and malnteln It on a rc,gular baslF. <br />I am enclasing all of the neceasary paperwork (use Ihe yellow Rebate Submltlal ChecklfeY). <br />Seiect hom the following: <br />7 �e contractor ldentified downapouts or other dralnape Illnes Ihal were oonnected lo my eewer <br />� Ilne (bahveen my houae end the fnslalled dev)cs) and ramoved, or rerouted them. <br />1 ❑ To my knowtedge, my property has no downspouts or other d�ainage cunneded lo my new�,r line <br />' (beN+een my house and Me Instelled devlce). <br />'� ❑ There ere downapoute or other dreinege lines conneded to my sewer line (between my house <br />_ and the instelled device). I undoratend thot Ieavin0lheae connedions creaies e riek of flooding <br />and 1 aooept thet risk. <br />/ r� � �7 � <br />lf� ' . / i ?:= ��S <br />Signature Dafe <br />____- - ---- ----- ------' <br />