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/14/2010 18:29 TEL 4253578857 Z 003 <br /> #.1"Pg Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: V\'- A.0 6 i yti <br /> Installation Address: L <br /> City: t1/.Qv,. M State: ‘,.9C • Zip: 9 no 3 <br /> Mailing Address (if different): Vim. <br /> City: "11Yl ' State: Zip;_ <br /> Email:7 1 U ii Y�Ce .0 hone: (2O( S 3— S'`l D 1 <br /> Total Cost to `Install Device(from contractorinvoice): $ 2�l �~ <br /> Please verify the following: <br /> the owner of the property where the backwater prevention device was installed. <br /> [ 'i worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> [ f contractor instructed me how to access, inspect, and maintain the device. <br /> ITKUnderstand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> ❑t--1ff sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain ft on a regular basis. <br /> Cr1 am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> 0 The contractor identified downspouts or other drainage Hines that were connected to my sewer <br /> line tween my house and the installed device)and removed, or rerouted them. <br /> o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between 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). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Signature Date 410141-5.-.- 1 6(1- <br /> /9.4-,/a/v krg / PUBLIC WORKS <br />