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i ^ <br /> Backwater Prevention Device Rebate Program <br /> Q, Rebate Application Form <br /> Property Owner Name: �7��l�n V e i�oC V e'� I <br /> Installation Address: ��I3 � �G M(3G�/D Avr._ <br /> Ciry: �;1 e✓{ �� State: !,✓� Zip: �Zo _ <br /> � <br /> Mailing Address(ildi(lerenQ: <br /> City: _ State: Zip: <br /> , [mail: <br /> Pi:or.:+: ( )� S2'��G7 I'II <br /> % I <br /> Total Cost to Install Device ((rom contracror invoice): S ____��o�%� — <br /> � - — —II <br /> Please verify the following: <br /> �j3� I am the owner of the property v+here the .ack�•�aler prevenlion device was insialled. <br /> �f] I worked wllh the contraclor to determine the location tor the backvrater preveniion device and <br /> understand that the decision regarding the location of lhe device�vas mine. <br /> � My co�tractor instructed me ho��� to access, inspecl, and mainlain the device. <br /> � I understand that I am responsible (or maintaining lhe backwater prevention device and keepinc� <br /> il in qoad v+orking order, unless it is installed in the city riyht-of-way. <br /> \ <br /> f�� If I sell my property, I will make potenGal buyers aware of the backe+ater pr�avention device and <br /> � lhe need to inspest and mainlain it on a regular basis. <br /> �] I am enclo,ing ail of the necessary paperv�ork (use the yelto.v Rebate Suhmitlal Checklisl;. <br /> Select (rom the foliowiny: <br /> [] The contrador identi(ied downspouts or other drainage Ilines tliat�vere connected to my sewer <br /> line (behveen my house and the installed device) and removed, or rerouted lhem. <br /> � To my knowled9e, ms� property has no downspouts or other drainage connected to my sewer line <br /> (belween my house and lhc installed device). <br /> � ] There are downspouts or other drainage Iines connected to my sewer line (betv✓een my house <br /> and the in;talled device) I understand that leawng these conneclions creates a risk of flooding <br /> and I acr_ept thal risk. <br /> Signature/�J�X Y� K�+*� __Date � � � ' �-- <br /> i <br />