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� <br /> I <br /> r <br /> �^%�� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> � - -------- - - - -- - <br /> � <br /> Property Owner Name: _�/ �_ �/�ZFE2 i <br /> Ins,allalion Address:__p��o�- d 7�'" (�� I <br /> I Cil�: �U�'�/ � Slale: /�� Zip:__���� �I I <br /> I !/ / � <br /> t�Aailing Address(if diNerent) ,_�70�7 7��G �L /y� i <br /> City i!�Cs�,�(Ji�`�-- State:_ �/�. _ZiP_�d�7� i <br /> Email: Q/IGj�PiP_S� ��U/J9JA/.G'a� _Phone (�loa)_(aS9— �/� � <br /> p' 2 ��� oo ' <br /> Total Cost to Install Device((r�m conlractorinvoice): 5_— — I <br /> I <br /> Please verlfy the following: ' <br /> i <br /> i <br /> �I am lhe oemer of lhe property v�here Ihe backwater prevenlion device e�as inslalled � <br /> � <br /> �I worked wilh the contractor to determine lhe location for�he backwater prevenlion device and + <br /> undersland Ihat ihe decision regarding the location of the device was mine. i <br /> �q �4y contraclor instrucl2d me how to access, inspect, and mainlain lhe device. { <br /> /� <br /> � understand that I am responsible for mainlaining the backwater prevenUon device and keeping i <br /> , d in good working order, unless il is installed in Ihe city right-of-way. � <br /> �If I sell my property, I �viil make polential buyers aware of the 6ackwaler prevention device and � <br /> the need to inspect and mainlain it on a regular basis. <br /> � / ! <br /> pq I arn enclosiny a�l of the necessary papenvork (use the yellow Rebale Submitlal Checklist). � <br /> Sclect(rom the following: � <br /> ] The conlractor i�'entified downspouts or olher drainage Ilines lhat were connected to my sewer � <br /> , line(belween my house and the installed device)and removed, or rerouled them. � <br /> f <br /> ' �To my knoe�led�e, r iy property has no downspou�s or olher drainage connecled lo my sewer line ' <br /> ��� (bet�veen my house and ihe installed device). <br /> � There are downspou's or olher drainage lines connecled lo my sewer line(belvreen rny house <br /> and the instal!ed device}. I understand thel leavinn �hesy connecticns creates a risk of flooding <br /> a�d l accept thal risk I <br /> I <br /> ! �� _ � <br /> Signarorc - � _ Date � ��J '�s <br /> i <br /> � <br /> � <br />