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. _�, - ._.._.._�. .� ---.__.,_ ---�- - -- -. -_ _.I <br /> -- _. ._____---�'--------" _` I <br /> ,' �i <br /> ` � Backwater Prevention Device•Rebate Pro9!"am `) <br /> } Ftebate App��cation �-or�r+ ; <br /> Evr�� --- � <br /> j � -- --� ; <br /> � ` �y_���__F_F_�� ---- I <br /> �� I Property Owner Name:._ _�__ � <br /> i �_31l,�--6�'-'a �C---_- I <br /> Installaticn�ddress: 3��_— i <br /> � � " .,� I <br /> ,'`-c/•1 ZiP.__ � <br /> State: ._____✓'r�--- I <br /> i c�iy: _�1/G._------ i <br /> , -- l <br /> p4ailing Adaress(if dif(elenlC__—�--- � , <br /> � Zip__--- -'J � <br /> 5��,� _- / y , <br /> � C�ry: _--- --- � L��� YF7 I <br /> � ,��,,,,,`n GLr'YL(oS��Y�K�O_-_GUUti Phone: ( `(,_---- i i <br /> t Emaii:_�"�!"�""— - <br /> � ���/ � V✓ _,��' <br /> Tolal Cosi ro Install Oevice ((rom contrac;or invoice): S - � � <br /> � �---- - ---------_ . , <br /> Please v_rify the follotvioip: � <br /> I ; <br /> � I am tr,e nemer of the p�operty wher2 the bac'�cvdate� p���ention de��nce ��+as installed. , <br /> C 1 <br /> I a�oriced�'�'ilh l!ie certraclor;o delerm���e IhE location fnr the b2c:tvJateGpBvefl[ietl dEvicB 8i1d <br /> � �'" understand tha'the decision reaarding 6�e location of tho device vaas mine. ; <br /> � . ! <br /> � �VI 1�ty contractor Insfructed me how to zr.cess, :nsp�et, and mainlain the devi�' <br /> , r , revention device and kaeping i <br /> t �� 1 under"star,d that I am rosponsible tor maintainiog tlte bockNater F + <br /> � it i�� gaod workinq oraer,uN=.ss it i=_ inslatlad in ihc ciry right-of-w�y� <br /> � I If I sell my p�operty, I wi�l mak� potenC:al buyers awara of li�e 6ackavater prevention device and <br /> the need lo���sPec�and m�inlain il cn a reg�.ilar b�asis. <br /> ' �I am enclosin9 all of the necessary paUEnvork (uSe the yellow Rebate 5uhmitt2l Ch9Ckli5ij. � <br /> ; Select!rom lhe followinp: � <br /> � �� The cMUt�ctof iden�i�ieC downspout:nr ather di ainage ilin�s tkat w�n:connected �o my sewer � <br /> i Iine(hetwecn my house and Ihe inslalleG devireJ and rort�nved, of fei'oul8d lh�m. <br /> �, � To my�:��ovAedne.my prqperty has��o downsP����s�r clher.tlrainaye cnnnected Io my sewer Gne � <br /> , � (betvieen my house and !ns insialled device). <br /> [I 7here are dnwnspculs or othendramage lines cOnneCiCd lo my sewe!line(betv�een iny h0u58 <br /> ! �nd Ihe:nsialled devfcel. I underslaM lha_[leawng these connecFons creales a nsk oF 1locding. ! <br /> � and I 2ccept Ihat ri,k. 4 <br /> i <br /> � <br /> / / �i <br /> � Signatur=_ -- _Date��/l_� i <br /> i � r <br /> � � <br /> � <br /> 1 <br /> � .._ ..._.. . _ .. .._ _..._. . . . ..... <br />