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. .. . .,_ _ _ _, _ . ___ _ ----. <br />,_ - - , <br />.` - , _ <br />�, _ <br />, <br />� . <br />, ,; . ; : <br />, <br />� � Backwater Prevention Device Rebate Program � <br />_ Rebate Applicatior� Form . <br />,, . I <br />(--- - � i <br />I' Properiy.Ownei Name. ��� ' i(i % \ �i.° � I <br />Instali �ho� /,ddress �_��._ fd � !C (J-Q . � i <br />� ���:� 4� ' ' I <br />Git;�`� . ,.�_��'. _ St2t� (/�.F�l _Zip _ _ - � <br />�. � � <br />, <br />trtailing Addr�ss (�f dilferenQ ��� � � � �� ,L � � � � � � <br />� <br />. - .. . . % .. ;� . � � . <br />� �f� � <br />.. ` . �.I�Y(� -_�.SiaiB. l�,��/Y-�^ �.j1�7. .- " ' � <br />�"� ':, —���Z .: � � , . �� <br />- - Fmzil _ . ��phone ri�Z�l� � - .J'� `'��S . ' , � � <br />`�\ � i <br />� � 701��1 C.ost to:tri's�ah Oevice`((rom contrdc.torrnvorce) S.��J '�-V�'�'' ` ! <br />� _ _ ; _ - <br />:. , <br />— ,i <br />Plea'sc�vcrify the.follpwmg,_ _ � <br />1 am lhe o�tnc� of the property �bhcre the bacl,water prevention dcwc;e was inslalied � <br />..� �.���� ` �'.' �; ,- ' �� - �' ����� ,��'' �� i <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) .,,�. � .. ' � � � � <br />i <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, . <br />, .. . . . . , .. , . � , . � . . i <br />. � <br />-� � �Signature/�� ;�I.,����.,ic�.�.�/7i � Date�iJ � , � <br />i <br />�T ���^ <br />