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; <br /> /M�'� Backwater P�evention Device Rebate Program <br /> � Rebate Application Form <br /> �— � � � <br /> Property O�mer Name: ��.ZCIY �'�f�GV� <br /> InstallationAddress: III� �aC.�i'iL �'fV�. <br /> City _�'�i1,f�� State: �� Zip:��j Z�J( <br /> MailingAddress(i,`diFerent): 7� 17GX S2�j� ] <br /> Ci,y:�ie ll'Pi��� State: w� Zip:�/�1G� ) <br /> Email: Phone: N�j �� `7335 <br /> Total Cost to Install Device(lrom contracfor invoice): 5 L`a�s �G <br /> -- ------- ( <br /> Please verHy the following: <br /> �m the cwner of lhe property�vhere the backwaler prevenlion device was installed. <br /> [�worked�vith Ltie contracbr to determine lhe lccal�on`or the backvfater prevention device and <br /> understand thzt the decision regardino;he location of the device was mine. <br /> �My contractor insWcted me how to access, inspect, and maintain the device. <br /> �r1 I understand ihat I am responsibie`or maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city righ,of-way. ; <br /> [.� If I sell my property, I�vill mahe potenlial buyers aware of the backvu�ater prevention Ceaice and � <br /> the need lo inspecl and maintain it on a regular basis. � <br /> L,✓ I am enclosing all of the necessary paperv�ork(use the yellow Rebate Submittal Checklist). � <br /> Sclect irom thc tollowing: <br /> �e conlractor identifi�d downspouts or other drainaye Ihnr,s that were connected to my sewer <br /> line(between my house and the installed device) and�emo�•ed, or rerouted lhem. <br /> [' o my knowledge, my property has no downspou�or olher drainaye connected lo my sewer line <br /> (between my house and the installed device). ! <br /> ❑ There are downspouts or other drainane lines cannected to my sewer line(betv��een my house I <br /> and;he installed device). I understand ihat leaving these connections creales a risk of fiooding ` <br /> and I accepl thal risk. I <br /> ,/ a � <br /> Slgnafure U - �'�' _Datc l � <br />