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�I <br /> 1 <br /> €�a�;k�yater �re�rer�ticse� 6?ev�ic� �ebate Prograr� I <br /> �, �8ebate A��@6ca�iora �or�ra i <br /> � <br /> Property Owner Name: �N Lu ����"� � <br /> Installation Address: l D��'� I ' " —` � � <br /> CRy: -��i�J� State: L1 v�Zip: `( a •'" �-� � <br /> Maifing Address(il dilterent): c-��}YV�� f <br /> City: State: Zip: i <br /> Email: Phone: ( ) c�Z�- ��LJ i <br /> Tolal Cost to Install Devicc (from contractor invoice): $ ����I U I ' �� � <br /> � <br /> I <br /> Plesse vcrify Yhe following: <br /> / i <br /> [�j/(am the owner of lhe property where the backv+ater prevention device was insfalled. i <br /> �rked with the contractor to determine the location for ihe backwater prevention device and j <br /> understand that the decision regarding the location of the device was rriine. � <br /> [� My ontractor instructed me how to access, inspecl, and maintain the device. ' <br /> understand that I am responsible for maintaining fhe backwalec orevenlion device and keeping ( <br /> it in good working order, unless it is instalied in the city right-of-way. ` <br /> � I sell my proparty, I will make polenlial buyers aware of the backwater prevention device and �, <br /> lhe need to inspect and maintain il on a reguiar basis. � <br /> f <br /> �] I am enclosing all of the necessary paperv�ork!usc the yellow Rebate Submittal Checklist). <br /> i <br /> Select from the follo�ving: <br /> [� The contraclor identified do�vnspou:s or olher drainage Ilines that were connected to my sewer i <br /> line (between my house and lhe inslalled device) and removed, or reroutetl them. i <br /> 1 <br /> � my knowledge, my property has no dcwnspouts or otfier drainage connected to my sewer tine ; <br /> (between my house and the installed device). <br /> �] There are do�vnspouts or other drainage lines connected to my sewer line(betwe=n my house <br /> and the installed device). I understand thal Ieaving tliese cnnnections creates a risk of Oo�ding ; <br /> :�nd I er,r,epl ihrH risL ', <br /> � <br /> r/ f� �,� �(� <br /> Srgn.aPurc_ ���� - ^--.D,:fe.y�v`�-�_��.Q._ <br />