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i <br /> Backwater Prevention Device Rebate Prv�rarT� � <br /> Rebate Application Form <br /> � -— ----- <br /> I � <br /> I froperty Ovmer(v'ame: _KF��"7� '(�L_C I I <br /> In;lalla(ion Address 3��`�� �/1�)a�� , <br /> - <br /> � c�ry: ������`�_ si,,��. L-�'<, z��, ��2.�/ <br /> I tilailing Address (if diHerenl) <br /> City: __ _ Stalc: <br /> - - - - Zip:.-- - -. <br /> ___ � <br /> [mail: Phone: ( � i <br /> — -- - -�--- - <br /> _ . . i <br /> i Total Cost to Install Device (Irrim conlractorinvn�ce) 5 i <br /> -- - - --- - -- .. .. - .. <br /> �. — _ _ _ - -- -- � � <br /> I <br /> Please verify the foilowing: � <br /> �`'�'I am the owner of the proper(y where lhe backwaler preven(ion device v�as installed I <br /> i <br /> r� I vrorked with Ihe contraclor to delermine Ihe location for i`�� hackwater F�venlion devlr.e and I <br /> understand tha; the decision regarding (he location of .ne Uevi;e was mme. <br /> i <br /> I <br /> �� My contractor inslructed me how lo acr,ess, inspec(, and rna�nlain lhe device <br /> [� I undersland thal I am responsihle for main�aining ihe backwaler prevenlien device ;ind keeping <br /> i! in good working order, unless il is in;talled in ihe city righ�-of-way. <br /> i <br /> �� I(I sell my properly, I will make polenlial buyeis aware of the backwatei pravenliun device .ind <br /> lhe need to inspnct and mainfain il on a regular basis. <br /> r.�j'�I am enclosing aIl of lhe nece:;sary paperwork (usr_ ihc yello:v Rebo�e Submitlal r�hcr.hlisl) <br /> Sclect from llic following: <br /> I. 1 �he con(ractor identified dotivn;pau�s or other dr;�in;�ge Ilines Ihat wera conner,led lo my sr.�v�r <br /> line (bclween my housr. :ind thr. ins�alled device)and rernoved, or rorouled Ihi�in <br /> ��) To my knowlr.dge, my property lias no downspouts or othcr drama�c connr.c�rd ��� my, .;cvn�r pn�; <br /> (bclween my hnuse and ifie in;lalled dcvicc). <br /> � j � Thnrr. arC downSpoulS or olher dr.inr,tgc lin��:cunnrr,�ed to my ;awrn lin�; (l�r��vc�,�i niy liuu�u: <br /> ❑n�� �hC installed dCVICe). I under.:fdnU Ih;II Ic�3v�nr� �hesc cnnn��diun:; ciurdi�s ,i u�.� uI Iluwlniq <br /> .nid I ar.r.cpl Ih�t risk. <br /> I <br /> Sir7n,3ti�rc_/ � ' � �rlS / �[:7� �j � <br /> 1�taS��--_ - — Uatc ' <br /> j ---- � I <br /> � <br /> I <br /> � <br /> I <br />