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. I <br /> � <br /> I <br /> Backwater Prevention Device Rebate Program ! <br /> Rebate Application Form _ <br /> ; <br /> � <br /> o ' <br /> , i <br /> PropertyOwnerName: �r���� �'ra'�-� � � <br /> Installation Address: � `6 ��7 �l C��C+tJ l�.1��L i <br /> c��y: ����._lf State: lc.�-� z�P: � � �.� I ( <br /> _� � 1 <br /> Mailing Address(if diHerent): � � �3� O'��� d`�— � ; <br /> �C4.w�3...0 _1..�-�16�.� State: I.L�FJ Zip: � `� � � '-- i <br /> Cily: j <br /> Emaii: C'i-.c�v�1...SQt� ��i C�J�. : Cc7ti.— Phone:�'�S) �7c'� -6? �� i <br /> 2�1- �� � <br /> � Total Cost to Inslall Device(from contracfor invoiceJ: $ ; <br /> L ' <br /> Please verify the following: + <br /> �I am the owner of the properly where the backwater prevention device was Instailed. ; <br /> _ � I orked with Ihe contractor to determine the location for the backwater prevention device and + <br /> understand thal the decision regarding the location of tlie device was mine. <br /> ['J�My contraclor instructed me how to access, inspect, and maintain the device. � <br /> [.�"I understand that I am responsible for maintaining the backwater arevention device and keeping i <br /> it In good working order, unless it is installed in the city right-of-way. , <br /> i � <br /> �.] If I sell my property, I will make potential buyers aware oi the backwaler prevenlion device antl ! <br /> the need to inspect and malntain it on a regular basis. � <br /> 0� I am enclosing all of the necessary paperwork(use the yellow Rebate Submillal Checklist). � <br /> Select irom the following: � <br /> ❑ The contractor identified downspouls or olher drainage Ilines that were connected lo my sewer <br /> ; <br /> line (between my house and the installed device)and removed, or rerouted them. <br /> � To my knowledge, my property has no downspouts or other drainage connected to my sewer line i <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connecled to my sewer line (behveen my house ; <br /> and the installed device). I understand thal leaving Ihese conneclions creates a risk of tlooding � <br /> and I accept that risk. � <br /> , ` �/� I <br /> Signature 1 ���V�' ' / ( " Date_ 1 � � <br /> --- I <br /> --. — -- --- — � -- ' <br /> � <br /> i <br />