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� Backwater Prevention Device Rebate ['rogram <br /> Rebate Application Form <br /> Property Owner Name: ��'/Y!�/Y! ����Q,1 <br /> Installation Address: / ( �� j�'� �. <br /> � � v [� p� <br /> City: liV���� State: ��1 Zip:�q_�� <br /> Mailing Address(if dil(erent): __ <br /> Cily:_ _ State:_ Zip: <br /> Email: _�Zu. �f/L��1 t.2 �_Co'!''� Phone: (��`f o2l'J�.�-�(i �9 <br /> Total Cost to Inslall Device ((rom confracfor invoice): � _._2� c7� ' <br /> �� <br /> Please verify lhe ivllowing: <br /> �am the owner of the property where lhe backwater prevention device was installed. <br /> L�worked wilh the conlractor lo delermine the location for the backwater prevention devlce and <br /> understand that the decision regarding lhe location o(lh� device was mine. <br /> r�/�v1y contractor instrucled me huw to access, inspect, and maintain lhe device. <br /> [�I understand lhat I am respansible for maintaining the hackwater prevention device and keeping <br /> it in good working order, unless il is installed in the city right-oi-way. <br /> (I sell my property, I will make polential buyers aware of Ihe backwaler prevention device and <br /> �he need lo inspect and mainlain if on a regular basis. <br /> � I am enclosing all oF Ihe necessary paperwork(use the yellow Rebale Submitlal Checkiist). <br /> Select from the following: <br /> U The conlractor identihed dovmspouts or other drainage Ilines Ihat wcre connected lo my sewer <br /> lin etween my house and ihe installed device) and rernoved, or rerouled lhem. <br /> To my knowledge, nry properry h3s no downspouls or olher drainaye connecfed to my sewer line <br /> (hehveen my house and lhe installed de:vice). :� <br /> � ] There are downspouts or other driinage lines cnnnected to my sewer line (between my house ? <br /> and the installed device). I understanti lhat lea���iiy U�ese conneclions creales a risk of Ilooding <br /> and I accept that risk. <br /> � /� ///.J <br /> i <br /> �'�'� Date r <br /> Signature _ �—���� <br /> - ---- . ._ - — -- --- — - - _ - -- --- - - � <br />