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- Backwater Prevention-Device Rebate rogram <br /> - - - -- <br /> Q, � Rebate Application Form <br /> � Property O�vner Name: �(�l C.E/�� � � �� A fZC p T I-- _-- —� <br /> I Installation Address. / 5 � �_� O�l T � <br /> r I <br /> City: �L_�" r State: _J�/�___Zip:��a. 0 � <br /> Nlailing Address(il differenf): �_j 0 `� �Nr� S � 5 �'-� ' <br /> City: —��LL?�1_T._ Stale: ��—Zip:�_Q._,�Q�_—_— <br /> FinaiC _ __ __ Phore: ( )__ <br /> Tolal Cosi lo Install Device ((rom contractor invoice): 5_�_��s1_� <br /> `------ - -- <br /> Please verify the following: <br /> �am the owner of the property where the backwater prevention device�vas installec' <br /> � I �vorked with the contractor lo dctermine the location for the backwaler prevention device and <br /> undersland lhat�hc decision regarding ihe location of the Jevice v�as mine. <br /> � A4 conlractor instructed me ho�v to access, inspect, and maintain the device. <br /> i I understand lhat I am responsible for maintaining the back�vater prevention device and keeping <br /> it i good working order, unless it is inslalled in the city right-of-way. <br /> If I seU my propeCy, I�vtll make potential Luyers a�vare of lhe backwater prevention device and <br /> the necd lo inspect and maintain it on a regular basis. <br /> ��m enclosing all of Ihe necessary papervvork (use the yellov✓ Rebate Submitlal Checklisl). <br /> Select from the following: <br /> Lf 1 he conlractor idenli(ied do�vnspouls or other drainage Ilines thal v�ere connected to my se�•�er <br /> li�(betwecn my house and lhc installed device) and removed, or rerouled them. <br /> ��.✓To my knowledge, my property has no downspouls or olher drainage connected tn my sewer linr <br /> (behveen my house and lhe inslalled device}. <br /> ;� There are downspouts or olher drainage lines connected lo my se�ver line(belween my house <br /> and �he inslalled device). I undersland lhal leaving Ihese conneclions creales a risk of�loodmy <br /> and I accept that risk <br /> i <br /> /J <br /> I Signature__ �v-�:�� � ., ate� � — `'1 � �J� <br />