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� <br /> �, <br /> � Backwater Preventior� Device Rebate Program ' <br /> Rebate Application Form <br /> i Property Ownvr Name --'l��vC'1� �u.� (1-L 11J✓ ---- — — <br /> � n i <br /> Inslallalion Address 1 � � S �_lIa" 3A 2i� %��G'^rV �3__ j <br /> C�ry _ �'�..'G-�12G'"L�' State L,�la Zip. 7tis� 1 ' <br /> � <br /> I <br /> hlailing Adtlress (if different): <br /> � <br /> j City: State _ Zip: I <br /> Email:txY.'�� bt�P�C,I.�S�C'ut�S'L�L�v�� . r�e,+Phone: (�-)�' �—�� —!�V� ' <br /> iTotal Cosl to Inslall Devir.e (Irom contraclorinvorc�): S Z� fvc / ; <br /> i { <br /> i <br /> Plnase verify the foilowinc <br /> �am the o�•mer of the property�vhere the backwaler�revention device was installed ; <br /> �iorked with the contractor to determine Ihe location for�he backwater prevention device and <br /> undersland that the der.ision regarding �ho location of the device was mine. <br /> �_�My contraclor instrucled me hovr to access, inspect. and maintain the device. <br /> i <br /> �understand that I am responsible for maintaining th� h�ckwater prevention device and keeping � <br /> il in good working order, uNess it is inslalled in the d' 'ghl-ot-way. � <br /> i�l �ell my property, I�v�ll make potential buyers aware of lhe bacMvater prevention device and i <br /> the need to inspecl and mainlain it on a regular basis. <br /> �f am enclosing all o(ihe necessary papenvork (use lhe yellow RebalP Submiftai ChecklisQ. j <br /> v <br /> Select from the following: � <br /> I <br /> �J The conlractor identi6ed downspouts or other drainage Ilines ihat�vere connected to my se�ver � <br /> line (between my house and ihe installed device) and removed, or rcrouted them. <br /> [�-f�To my knowlydge, my propetty has no downspouts or other dramage connecled to my sewer line <br /> (behveen my hnuse and lhe inslalled device). <br /> (] There are downspouls or other drainage lines connecled to my sewer line (between my house �� <br /> and the inslallr.d device) I understand Ihat Ir.aving these conneclions cre.ates a risk of floading � <br /> and I accept ihat risk <br /> c,� � i� � <br /> Signature/>�lftL.r���/Zlti.�, Datc � '.�� " zp j S I <br /> i <br /> i <br /> i <br />