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� <br /> �� BacCcwater Preventian Device Rebate Program <br /> �'�'��� Rebate �pplication Form <br /> �3,�„ <br /> Property Owner Name:_ C��.�� L(v��/ <br /> � <br /> Installation Address: �COZ No� ��E <br /> City:_�j c�_�" Siate' LL/iQ Zip:«o��l� <br />; Mailing Address (ildillerent): <br /> City. Slale: Zip: __ <br /> Email: Phone: (�) 2.31- UU33 <br /> I Total Cost to Inslall Device (I�am �ontractor invoice)-5 — _ I <br /> L � <br /> Please verify the following: <br /> [/� I am the owner of the property where the backwater prevention device was inslalled. <br /> �worked wilh the conlractor lo determine the location for Ihe backwater prevention device and <br /> undersland that the decision regarding lhe location of lhe device was mine. <br /> [�My coniractor instructed me how to access, inspecl, and maintain lhe device. <br /> �I anderstand lhat I am responsible for maintaining the backwaler prevention device and keeping <br /> in good working order, unless it is installed i�the cily righl-of-way. <br /> If 1 sell my properly, I will make polenlial buyers aware of the bar,kwater prevention device and <br /> � fle need to inspecl and maintain it on a regular basis. <br /> [� am endosing all o(Ihe necessary paperwork (use lhe yellow Rebale Submiltal Checklisl). <br /> Select(rom the following: <br /> ❑ The contractor identi(ied downspouts or other drainage Ilines that were connecleA to my sewer <br /> line (belween my house and Ihe inslallod device) and removed, or rerouted them. <br /> �o my knov+ledge, my praperly has no dov+nspouls or olher drainage connected to my sewer line <br /> (belween my house and Ihe inslalled device). <br /> ❑ There are downspouls cr olher drainage lines conner,led to my sewer line (belween my house <br /> and Uie installed devic;e). I understand lhal Ieaviny lhese conneclions creales a risk of floodiny <br /> and I accept Ihal risk. <br /> Signatarc/����� Datc Z1 � <br /> � <br /> I _._ – _ �_ <br />