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--�r- — —�---�-- — -- <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> PropertyOwnerName: �Un Gp �lYl(�.Lt ����U __ <br /> Inslallation Address: aaOG l–UVV1��Yu� — <br /> ;.ity.t����.'re.'{–t State: �� ly Zip: � �Z.Q � _ <br /> IMailing Address(ildilferenfJ: _ <br /> �y�y State: Z�p: <br /> �_ ��.,��: L_l�ell�� LO�Z� c�ol, cmti� Phone: (4z� �SZ "y�c`�.3 _ <br /> — � I <br /> I i clal Cosl to Install Device ((rom contractor invoice): 5 _ <br /> J <br /> Please verify the following: <br /> ���am the owner o(the property v�here the backwater prevention device was installed. <br /> ❑ i worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location o( the device �vas mine. <br /> ❑ A4y contraclor instructed me ho�v to access, inspecl, and maintain the device. <br /> I ❑ I understand thal I am responsible for maintaining the backwater prevention devi ce and keeping <br /> it in good working order, uniess it is installed in the city right-of-way. <br /> ❑ If I sell my property, I�vill make potential buyers aware of Ihe backwaler prevention device and <br /> the need to inspecl and maintain it on a regular basis. <br /> ❑ I am enclosing all of the necessary paperwork(use the yellovi Rebate Submittal Checkiist). <br /> Select from the following: <br /> � The contrector idenlified downspouls or olher drainage Ilines that were connecled �o my sewer <br /> line (between my house and the installed device) and removed, or rerouted them. <br /> �To my knowledge, my oroperty has no downspouts or other drainage connected lo my sewer line <br /> (between my house ;�nd the installed device). <br /> ❑ Thero are downspouts or other drainaye lines ccnnecled to my sewer line(between my house <br /> and the installed device). I understand that leaving these conneclions creates a risk of Ilooding <br /> and I•accept that risk. � <br /> � Signature � . ��/� � ! Date � ��J <br /> i <br />