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<br /> . �� � Backwater Rrevention Device Rebate Program. � � �
<br /> �:' �w�,.� , Rebate Application Fortn. ' � .. . : ' � . .
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<br /> ' � Property O�' ��er tJania: �(r,' '�/�� �i �'0��4zJ .�� , ' . , I
<br /> • � Installatlon Address: . ' . � .. • . I
<br /> i City: ( l.�/lUJ::Z�) State: Zip, G ���� : ' ... . " � I
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<br /> • Mailing'AdJ�:ss(it diHerent):� ��A 0 ' . . 1 ' ,
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<br /> - ��y. Stata: ... . �p. _ .
<br /> I , � • .. Eriall: � � ' � Phone:�( I.) '_ �' • • • . 1
<br /> ` � Total Cost to Instell Device(from contracforinvoiceJ: $ • ����✓: • �
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<br /> , • Please veN(y the following: . • ,
<br /> � . � I arti tFie owner of lhe ptoporty where Ihe backwater prevention devjce was installed. �. � • � �
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<br /> _. �I worked with the conlractor to determirxi the location for the 6ackwaler preven6on device ard .
<br /> understand thal the deoision regarding the Ioc:aUon of the dovice was mine..•, ' �'��• ' ' � �
<br /> � � ,�My contraclor instructed me how to aaess, insped,and malntain the device: "• �� ' � '; � . � : I
<br /> i� � :;, ., . .
<br /> � I understand that 1�am responsihle for maintaining the backwater prevenGon devlce and keepng : �
<br /> it in good�+rorking�order, unless it is installed in the city riyht•o(i+ray: _ , �
<br /> . �'If I sell my property, I will make potential buyers awaro oF Ihe backj4alei prevention device and , ' • • • :
<br /> •. thc need to inspocl ond mair`eln II on o regular basis. , ; . • � . . . � , ' '' �=,-
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<br /> � �I ani ench�sing al!oi Ihe necessary paperwork(use the yctiow Rabete S.bmiltai Checklistj: ,;.,;:. , �'
<br /> ' Select from lhe icHlowing: ' , • � ' '' � , , ,
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<br /> • ❑ The contreclor idenHtied downspoufa or olher drainage Ilines thel were connectad to my sewer . - ' , ' •
<br /> � tine (hetween my house and the instaqed device)end removed, or rerauted Ihem. • ' . ,'� • � •, '
<br /> �To my kno�vlc0ge. my pruperty has no dovmspou!s or other dra�nage connected to my sewer line•• . :,. � •.
<br /> (between my house and the inslalled devico).� '` `
<br /> ' . �,J 'nere are downspouts or oUier dreinage Ilnes corinected to my searer line(between my�house ' . � �
<br /> �and the inslailed devic�).,I undorctand that leaving lhoso conneclions creates a rlsk of fiooding ' '
<br /> .. � and I accept thal risk. ' . . ' -g. : `
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<br /> Slprtalure' .~. ` . Dota ' �•� , � ' • • �• . ,
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