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_ _ ._ - --• �-----___- ----- --- _._.- -�— - ---�- - - -- <br /> Backwa�er Prevention Device Rebate Program <br /> Rebate Application Form <br /> PropertyOwnerName: �eMn.-ttr � Lvo-� ��1�lcn� � Si?�11�'�r v� afit�c{Sl <br /> r � � <br /> Installatic� Address: ��n� �� y�-�� ��- � <br /> City: Cvcwit State: �� Zip:--_ r'182u1 <br /> Maiiing Address (i(diffe�ent):__ � ��X _ 1�,� __ <br /> City:_ �.v�c� l�w- _ Slate: 1✓�t_ Zip: `�2r! __ <br /> Email: ���� �Sw� �. wm�`�3'�. '��"f" Phone: (Zw) �,� 'S`I�y <br /> Total Cost to Install Device (lrom confracforinvoice): $ `�—�q 2 . Z'� <br /> Please verify the follo�ving: <br /> � I am the ovmer of the pruperty where the back���ater prevention device was installed. <br /> � <br /> � 1 worked with the conGactor to determine the Iocation for the backwater prevention device and <br /> � understand thal lhe decision regarding the location of the device was mine. <br /> � tvly contractor inshucted me how to access, inspect, and maintain the device. <br /> � I understand that I arr� responsible tor maintaining the back�vater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-v�ay. <br /> � It I sell my property, I will make polential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> [� I am enclosing all of the necessary paperwork (use Ihe yello�v Rebate Submittai Checklist). <br /> :elect f,-om the following: <br /> ❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> line(between my house and the installed device) and removed, or rerouted them. <br /> � To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are do�vnspouts or other diainage lines connected lo my sewer line(belween my house <br /> and lhe fnslalied device). I understand that leaving ihese connecllons creates a risk of Oooding <br /> and I accepl thal risk. <br /> 11?- � z� � <br /> Signatw e _Date <br /> ' �� <br />