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c__'_, - _ _ . _ _ _ _ . . .. . <br /> _ _ . J <br /> —, .- <br /> -- . _ _ . _ ___ . <br /> f - ---- - - - _-- - ------- ---� -- — ------ ---- . _ I <br /> j I <br /> I Backwa�er Prevention Device Rebate Program '' <br /> I �� Rebate Application Form ' <br /> ' `]_'" i <br /> i <br /> ----- -- i <br /> y � <br /> II Property 0�•mer Name �`��� `� ��'r��aN�~ Lt�C.I�� e�k=er1 � <br /> I In,tallalionAddress�. igUz �mba"r� /-�Ve� ; <br /> { <br /> �, Ci�y. CVe��2'I-� _State VJ/� Zip. ��10 � I <br /> I <br /> I Mailing Address (il dillerent):_ <br /> Cily: Stale: Zip: I� <br /> i <br /> � <br /> � Email: h�'rbl edUII (oD�LO✓Y1C�25�.h�� phone: (�IZ� �{13-1�8 i <br /> � Tolal Cosl lo Inslall Davice(lrom confractorinvoice): 5 3��-1 ' �� <br /> i <br /> � ----------- -- I <br /> Please verity tho following I <br /> I <br /> I � I arn ?he owner ot the propeny where the � .:water prevention device was installed. <br /> I <br /> I � I worY,ed vrith lhe conUador to determine the �oCation for the backvdater prevenlion devlce and <br /> i understand Ihal Ihe decision regarding the location of the device was mine. <br /> � � My coniractor instrucled me iiow to access, inspecl, and maintain lhe device. � <br /> I <br /> 1 ;QQ, I understand Ihal I am responsible for maintaining the backwaler prevention device and keeping . <br /> , It in gaod v�orking order, unle�ss it is in;lalled in the city riqht-o(-��+ay. <br /> i �1 If I sell my property, I v+ill make potential buyers aware ot the backwater prevenlion device and . <br /> Ihe need to inspect and maintain il on a reyular basis. . <br /> i � <br /> � � I am enctusing all of thr. necr.ssary papenvork (use the yellow Rebate Submittal Checklisl). <br /> r { <br /> � Selact from the following: � <br /> � <br /> � ❑ The wnlractor identified do�vnspouts or other drainage Ilines that were connecled lo my setver ' <br /> line (belween my house and Ihe installed device) and removed, or rerouted them. ' <br /> �,'io my knowledge, my property has no downspouls or other drainage connected�o my sewer line <br /> I (belvdeen my house and the installed device). '�, <br /> �I [� There are downspouls or olher drainaye lines connected la my sewer line (beRveen my house <br /> � and the installed device). I understanA tl�at leaving �hese conneclions creates a risk of Oooding � <br /> Iand I accept thal risk. <br /> � .� ' ) � <br /> Signature+�`k�3@JcCI-- r�j1t. �:-�'�t,-x.c���L4�' Datc 3 f I� I�I S � <br /> � , <br /> � <br /> I <br /> i � <br /> I � <br /> � . _ � <br />