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-1 <br /> Backwater Prevention Device Rebate-Program <br /> Rebate Application Form . <br /> r �� � <br /> ProperlyOwncrNarne: ,���✓M,�C /yk���?d�r1N� � <br /> Insto'alion Address: �o n' � �"($Pi,�� •S� I <br /> city:�v>>��;1� state: �, zip: �f-'Z�� <br /> MailingAddress(iidif,erent): �50� �iJ� �),�.�cD:� .�S <br /> City: f,;.-���i�t. State: �/P— �p: � 7 Z�-'� <br /> � ' ' / n � <br /> Emaii: �o.���> ._ �v(�ON�d .�Y�U� Lu1/' Pn�ne:��3) Fs�l �J% �,'�� <br /> Total Cost to In tall Device (hom confractor invoice):$_ <br /> Please verify the following: <br /> [� I am the owner of the property where the backwater prevention dedice v�as installed. <br /> (�j I worked wilh the contraclor lo determine lhe Iecation for the backwater prevenlion device and � <br /> undersland that the decision regarding the localion of ttie d�vice was mine. � <br /> �,I My contractor instructed me how to access, inspect, and maintain lhe device. � <br /> (� I understand that I am responsible for main!aining the back�vater prevent�on device and keeping I <br />� it ir,good working order, unless it is installed in the ciry iight•of-way. <br /> � If I sell my prope�ty, I will make potenlial buyers aware of the backwater prevention device and <br /> the need to inspect and rnaintain it on a regular basis. <br /> �f I am enclosing ali oi the necessary paperwork (use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> � The contraclor idenlified downspouts or olher drainage Ilines that were connected io my sewar <br /> line (belween my house and lhe installed device)and removed, or rerouled them. <br /> �] To my knowiedge, my property has no downspouls or other drainage connecled lo my sewer line <br /> (betv�een my house and the installed device). <br /> ❑ There are downspouts o�,othar drainage lines cennected to my sewer line(between my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I arcepl that risk. <br /> � <br /> _/// <br /> / ��� <br /> Signature �i � r�_,^,ate <br />