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-�—------ — ----- - -� -- <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> �Property O�vner Name: �!// �t � �cJ e/�1�`�����'� <br /> � Installation Address: ��O� ���PS �c/c' <br /> City: �l/eY� / ' Stale:� Zip:���/ <br /> Nlailing Address (if different): <br /> �I City: State: Zi <br /> P'-- <br /> li� Email:� �O dCUh-i Cc�.Sf VJe� Phone: (y�5} „2S� � a7 �'� <br /> Total Cost to Install Device ((rom confractorinvoice): S <br /> Pleasc verify the following: <br /> � I am the o�vner of the property�vhere the backwater prevention device was installed. <br /> �� I ��rorked �vith Ihe contractor to determine tY.e location for lhe backv+ater prevention device and <br /> ti- <br /> understand thal the decision regarding t:e location of ihe device was min�:. <br /> ��fviy contractor instructed me hov�to access, inspect, and maintain the device. <br /> i � I understand that I am responsible (or maintaining the back�vater prevention device and keeping <br /> ' it in good working order, unless it is installed in the city righl-of-ti•�ay. <br /> � If I sell my property, 1�vill make potential buyers aware of the backwater prevenlion device and <br /> the need to inspecl and maiMain it on a renular hesis. <br /> � I am enclosing all of lhe necessary papenvork (use the yellow Rebale•Submillal Checklist). <br /> Select (rom iiie following: <br /> N�j The coNraclor identified do�vnspout;or other drainage Ilines thal were connected lo my sewer <br /> line (behveen rny house and ihc installed device)and removed, or rcrouled Ihem. <br /> iU�1�f'o my knowledge, my property has no downspouls or other drainage connected to my sewer line <br /> (�etween my house and lhe inslalled device). <br /> �11 n There 2re downspouts or other drainage lines connected to my sewer line (behveen my house <br /> and the installed device). I undersland thal leaving ihese conneclions creales a risk o((looding <br /> and I accept lhat risk. <br /> i <br /> �.�/ ' y,/ 7 <br /> Signatur � / �� � ���''�/ / Dafe `� ��/� <br /> /� <br />