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Backwater Prevention Device Rebat� Program <br /> Q, Rebate Application Form <br /> �—— ..� <br /> � Property Owner Name: �C».,K_��LjJ J h O <br /> InslallalionAddress: ����i �7N'1l'�+.c�d�,[f/' <br /> ' �i Ciry: —l��L E- Slate: �VG�, ZiP:����� _ <br /> _ , i Mailing Addr,>_ss (il dif/erenQ: ____ <br />�� 7f� City: Stale: Zi <br /> _.r. — P— — <br /> i � <br /> Email: Phone: j�`/,���� � <br /> i --- <br /> �1 � O <br /> Total Cost to Install Device (from contrecfor invoice): $�6`"� • <br /> I - — I <br /> Please verify the following: <br /> C�m the o�vner of the property �vhere the backwater prevention device was instatled <br /> [� worked �vith the contractor to determine the location (or the backv�ater prevention device and <br /> understand that the decision regarding the location of ihe device was mine. <br /> [�y contraclor instrucled me how to access, inspect, and maiNain the device. <br /> understand that I am responsible for maintaining the backe�ater prevention device a�d keepiny <br /> it in good �vorking order, unless it is installed in the cily nght-of-�vay. <br /> ��Ff�ell my property, I will make poten!ial buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> am enclosing all of the necessary papenvork (use the yellotiv Rebate Submittal Checklisl). <br /> Select from the fallowing: <br /> [ ] The coniractor identi(ied downspouts or other drainage Ilines lhat were connected lo my sewer <br /> line (behveen my house and the installed device) and removed, or rerouted them. <br /> n my knowledge, my p�operty has no do�vnspouts or othe.r drainage connecled to my sewer line <br /> (behveen my house and ihe installed device). <br /> ❑ There are duwnspouls or other drainage lines connecled to my sewer line (belw�en my house <br /> and the inslalled device). I understand ihal leaving Ihese connecfions creates a risk of flooding <br /> and'I accept that risk. <br /> Signature, �'�� � 7 ��r'�C� Date �c� rU- �0/�j <br />