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Backwater Prevention Device Rebate Program <br /> Reba7e Application Fc�rm <br /> Property0wnerName: h�Gt�t'I � G�V1 �- She I I�� �'������ <br /> Installation Address: � 6�-I ,�q�C �tre <br /> City: ��P rP � State: W H` Zip: ��� I <br /> Mailing Address (it dilferent): <br /> i <br /> Cily: State: Zip: ; <br /> � <br /> Email: x M G��G l/ � W1�((1 -�0✓✓1 Phone: ( ) Zb 6 ,_�1 �` ���� I <br /> 7otal Cost to Install Uevice (lrom confracforinvoice): 5 ��� <br /> Please verify the following: <br /> ,0^I am the owner o(the property where the backwater prevention device�vas installed. <br /> �"I worked with the contractor to determine fhe location (or the backwater prevention device and <br /> understand lhat the decision regarding lhe location of tlie device was mine. <br /> �My contractor inslructed me how to access, inspect, and maintain 4ie device. <br /> �i understand that I am responsible for mainlaining the backwater prevenlion device and keeping <br /> d in good working order, unless it is installed in the cily righl•of-way. <br /> �If I seil my property, I will make potential buyers aware oi the backwater prevention device and � <br /> the need to inspect and maintain il on a regular basis. ( <br /> �f am enclosing all of lhe necessary papenvork(use Ihe yellow Rebate Submittal Checklist). � <br /> Sclect from thc following: <br /> ❑ The contractor identified do�vnspouts or other drainage Ilines that were connected to my sewer <br /> line (belween my house and the instailed device) and rr_moved, or rerouled them. <br /> �"�To my knowledge, my property has no downspouls or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connecled to my sewer line (between my house � <br /> and Ihe installed device). I undersland Ihat leaving ihese connections creates a risk of flooding � <br /> and I accept ihal risk. � <br /> I <br /> IL/ � <br /> Signafure� Dafe ! �s i <br /> � — t <br /> I <br /> , <br /> i <br /> i <br />