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i <br /> B�ckuv�fier �reve�tion Device i2ebate l�rogram � <br /> Rebate ,4ppli�ation Form � <br /> I <br /> i <br /> ,--- , <br /> ' Property Owner Namo: ' r i c" /-� � U�-/ r.l� � <br /> � <br /> I Installa6on Address: /L.��1/ � c�✓�'�/'l�f'� /a vi! _ � <br /> ! <br /> j <br /> � Gty' ��Z% Slate: ' � /� Zip:�;�Ci� � <br /> i <br /> A4ailing Address (1f diHerent): ' <br /> i <br /> � <br /> City State: _ Zip: <br /> [mail: Phone: (5�;) `h�6�1•-l��l��J � <br /> ; Total Cosl lo Install DeviCe ((rom contracfor invoice): S_���� �5�!�� _ <br /> � ' <br /> � _ i <br /> I <br /> Please verify the following: ( <br /> dI am the owner o(lhe property where lhe backv�ater prevention device was inst211ed. � <br /> dI worked v.ith Ihe conlraclor to delermine the location for lhe backa+ater prevention device and � <br /> understand Ihat lhe decision regarding the loc„ n of the device was mine. � <br /> � My contractor instrucled me how to access, inspect, and maintain the device. � <br /> [�I undersland thal I am responsi�le for maintoining lhe back�vater provenlion device and keeping <br /> it in good working order, unless il is installed in the city right-of-way. <br /> J IF I seli my property, 1 will make potenlial buyers aware of lhe backwater prevention dovice and � <br /> the need to inspect and maintain it on a rr,gular basis. <br /> �I am enclosing all of the necessary papeRvork(use Ihe yollow Rebate Submiltal Checklis�). <br /> I <br /> Select from the following: <br /> I <br /> ❑ 1 he coNractor identified downspouts or olher drainage Ilines thal�vere connected to my sewer � <br /> ime (behveen my house and the installed device) and removed, or rerouled lhem. � <br /> i <br /> [+� To my knowledge, my property has no dotivnspouts or othcr drainage connected lo my sewer line <br /> (between my house and lhe inslalled devir.e). <br /> ❑ There are downspouls or other drainage lines connecled to my se�ver line (between my house <br /> and the instatled device). I understand lhai leaving Ihese cenneclior�s creales a risk of ilooding <br /> and I accept that risk. � <br /> i <br /> i <br /> Signature �. , 1 � �✓ Dafe ��/ �•� i �� <br /> i <br /> / ' <br /> � <br /> � <br />