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�,�/� Backwater Prevention Device Rebate Program <br /> �� Rebate Application Form <br /> �-- - - - , -- � <br /> i Property O�vner Name: CSL�C� L7?i(Y<S�� <br /> InstallationNddress:_ I�o/ HG•/i �C � <br /> � Cify; L32S'I�TT Stale: LV — ZIp: lA�L7U __ I <br /> Ii:lailingAddress(i(dil(eienf): /�1`IoG /F'� � Si: �(/c _.__ _ <br /> � City: !?1�bZ� State:�_Zip: rJEZ7.? <br /> , Email: L?iet-Pr�c�sou��iu�al. ��t . wc, .u� Phone: (�Go) 43)�-�i)3d <br /> ITolal Cost lo Inslall Device(lrom r.onlractor invorce): S__ I <br /> � -- ----- � <br /> Please verify the following: <br /> �am the oeme�of Ihe property vrhere lhe backc�afer pra�ention device was installed. <br /> ❑ I worked with the confractor to delermine the local�on for lhe back�vater prevention device and <br /> understand that the decision regarding the bcalion of the device a�as mine. <br /> j��4y contractor inshucted me hoei to occess, inspect, und maintain the device. <br /> ���understand that I am responsible for maintaining tLe backwater prevenlion�evice and keeping ' <br /> it in good�•�orking order, unless ii is ins�alled in the cly righ�-of-r�ay. I <br /> f�f I sell irry�roperly, I vdill make polenlial buyers ae�are o(the hackwater prevention device and <br /> :he need to inspect and ��,aintain it on a regutar basis. - <br /> [ [}"I ain enr,losing all o(Ihe ner.essary �.�pen•:ork (use the yello�t�Rebale Submiftal Checklist). <br /> Select from tlie following: <br /> ;� The conUactor identified dovmspouls or olher dralna�e Ilines Ihal u�ere ronnected to my sev�er <br /> hne (behveen my house�jnd the installed device)and removed, or rerouled them. <br /> ���Tn my kno�vlr.dge,rny propr.r�y h�s no downspouts or othr.r drainage connected to my set'+er linr <br /> (beh^.�een my f�ouse and thc Installed devlce). <br /> �� Thena are dok�nspouls or othar drainage linos connected to my sewer line(bet.veen my house <br /> and Ihe installed device). I understand lhat leavin�these connections creales a risk oi tlooding <br /> and I accept �hal risk. <br /> (/' � � <br /> Signalure / � ' __Date � �7 �S <br /> L � <br />