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<br />� � Backwater Prevention Device Rebate Program �
<br />_ Rebate Applicatior� Form .
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<br />I' Properiy.Ownei Name. ��� ' i(i % \ �i.° � I
<br />Instali �ho� /,ddress �_��._ fd � !C (J-Q . � i
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<br />Git;�`� . ,.�_��'. _ St2t� (/�.F�l _Zip _ _ - �
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<br />trtailing Addr�ss (�f dilferenQ ��� � � � �� ,L � � � � � �
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<br />- - Fmzil _ . ��phone ri�Z�l� � - .J'� `'��S . ' , � �
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<br />� � 701��1 C.ost to:tri's�ah Oevice`((rom contrdc.torrnvorce) S.��J '�-V�'�'' ` !
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<br />Plea'sc�vcrify the.follpwmg,_ _ �
<br />1 am lhe o�tnc� of the property �bhcre the bacl,water prevention dcwc;e was inslalied �
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<br />L� I viorked witfi�the cOntrctor to deterniine thP locahon for tne bacKeiate� prevention d'evice and
<br />,,' r�� ur;dustantl lhet lhc.decision r..gartling lh� lo..afiumof thc devtce �4as'mine ' `;,,;
<br />� � P9y;contractor insV��cted me how to acc�ss ��spe..t �and mzmtain lhe'dPwce �
<br />s [�I ulidersfarid.lhat I am'respcnsible for nnmt inir,g the I �chv+ater pr�ienuon device and kceping
<br />�� it iri yor.d evorkingordcr;'un!ess it is iristalled.i�,tt�e city right-of way.;�, . . . � '�� ��
<br />,�If I,sc,ll my property� I t+ill �iiiake pd.chti 31 �uyr r's aware o( fhe b�c,kwater prevention device and �
<br />'� B�e'ne..d t�, ui�pc�t.��na maint.vn it ofi a reyular Casis., _ � '' '
<br />,"� �La;n cn,losing �I' oF the riec���ary.pap�nwrk (use lhe yello�� Re6ate Subnuttal Checkl st)'
<br />Selcct (rem thr, followin�: : � , .
<br />,�[� ��7hc rnnincfor,i�unlified��do.vnspnids;or otheFdra��zge Ilines Shaf.ever� co�inecled�to my sewer � ��
<br />��� hiic (briv�cn,my houy� �ind lh� �ns(alf� dcwce);and remoJ�d pr.rerouledif7em. � i
<br />��' � I<� my knrwletlge my ��;iopPiry h i� no do�mspouts or other cli aui �qe�r,unn� ctc{1 to my sevJer Ifne � . �
<br />�� �iebneen my�hou e aiidllir m�tallecl'rk � -e) .,,�. � .. ' � � � �
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<br />- � � I here are i{ovins{�c,,uts or othor diaiiiagr h�es c�Pnerled to my �,;;�ver Gne (het�Neen my house .- ��
<br />�and ihe i�istalled device):;1, understand tf�a[ leawng (hase cbnnections creates a risk of flooding ' .' �
<br />' ;aiid l'aae��f tlial iisk, .
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<br />-� � �Signature/�� ;�I.,����.,ic�.�.�/7i � Date�iJ � , �
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