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�,�}�' Backwater Prevention Uevice RAbate Program <br /> ��— Rebate Application Form <br /> w�v�r,rrci i <br /> �� <br /> v L(}t,(�Gil L.E+-C�i�s , —. <br /> Property Owner Nam=: /�1 �'�0 `f�'—' <br /> Installation Ac:dress: �� 'S J � ���1*2.��==��'` <br /> i <br /> Ciry �"��� Slale: �t/� Zip;_ % �' �� � <br /> MailingAddress (ifdiNerentJ: /�"G—^--t <br /> City: � State: -- Lip: ' — ' <br /> EmaiC � %y�/CC C!� C✓r:�rc.C•r.,..�`. .+.c�'�Phone. ( '�f 3 or ' _ j`�d� <br /> Total Cost to In�tall Device (lrom contracror invoice) S .�,5 d O, er <br /> Please verify the following: <br /> �J I am the owner of lhe property where the backwater prevenlion device was i�stalted. <br /> yl I �vorked�vith ihe contractor to determine Ihe location (or the 6ackweter nrevention device and <br /> � understand thal Ihe dec�sion regarding the IocaUon of ihe device was mine. <br /> I Y My contractor instrucled me how lo acces, inspect, and maintain Ihe device. <br /> �I understand that I am responsible tor mainlaining the bac::::ater prevenlion dewce and keeping <br /> it in g�od e�orking erder, unless it is inslalled in the city right•ot-way. <br /> �/' If I sell my property, I will make pctential bupers aware�;the backwater prevention device and <br /> T the need to inspect and maintain it on a re�ular basis. <br /> rJ( I am enclosing all of the necessary papenvork(use the yellow Rebate Submittal Checklist). <br /> /— <br /> Select lrom thc following: <br /> The contractor idenlified dov+nspouls o� other drainage ,�ines Ihal were connected to my sewer <br /> line (hetween my house and the installed dewce) and removed, or rerouted Ihem. <br /> I/I lo my kno�vledge, my property has no downspouls or other drainage connected to my sewer line <br /> � (hetween my house and the installed device). <br /> ❑ There are dovmspouts or olher drainage lines ccnnecled lo my sewer line (betw?en my house <br /> and Ihe installed device). I understand ihat Ieavin� Ihese connections creates a risk oi Ilooding <br /> and I accept that risk. <br /> Signeture f.1/!��-�'��" �-�i���% � Datc s" �—�S � <br />