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f <br /> � i <br /> i <br /> rn� Backwater Prevention Device Rebate Program i <br /> C�`'� Rebate Application Form � <br /> ��.". <br /> ; <br /> i <br /> I 1 � <br /> PrcpeRy O�mer Name: �l P.5���� fNvtiiS�• �i�t � <br /> Inslallation Address ,2l 3 � ��n � 5 I __ � <br /> I ' <br /> CitY. ��«�k Stale: L.J/� Z�p ���� e I � i <br /> i � <br /> h�tailing Atldress(ildd(erent) � <br /> i <br /> Ciry State Zip ' <br /> Errail. _[�,�� ti�.,:lc�� l'o,�c�tE. ��r_�- Phone ('u5),2�9-']E3`!4 I <br /> ��, Total Cost to Install Device(from confractorinvoice) : __a r�y�(. 5� <br /> I ' <br /> Please verify the follawing: <br /> � <br /> �I am the owr,er of tne proGerty wLere lhe ba�kwater prevention dev:ce was inslalled , <br /> ��eorked witn the contracror to determine the IocaUon for,he backwat=r prevenP.on devte and <br /> understand thal the decis on reaarding the location of the device was mine j <br /> � fdy contractor instructed me ho�v to access, inspect, and maintain the device. � <br /> i <br /> [�I understand that I am resoonsible for maintaining tne baclnvater prevention dewce and keep nr, j <br /> it in good workina order, unless it is instslled in lhe city nght-o(•�vay. <br /> [�If 1 sell my pwperty, I v�dl make poterlial buyers aware of the back�:�a:er c•eventicn device and c <br /> the nced to mspect and maintain il on a regular bae�s � <br /> � <br /> ��I am encbsing all of the necessary papernork(use tne yello�:� Rebale S�omittai Cbecaiis,) � <br /> Select(rom the (ollowl�g: � <br /> �i'fle contractor iderlified do�vnspouts or other dramage Ilines th�t�sere connected to my sewer � <br /> line(be6veen my house and the instailed device) and removed, or rerouted ihem. <br /> �/ i <br /> !� lb my knowledge, ry property has no do�•.nspouts or other draina�e connecled ro my se�ver line j <br /> (between my house and hc installed device) � <br /> ❑ I here are downspouts or olr.er drainage lines connected to my sewer line (beM�een my house ; <br /> and tlie mstalied device) 1 understand thal leaving ihese conneclions creales a ris4 of tlooding ( <br /> and I accep;tha: risk. <br /> I <br /> I <br /> � <br /> Signature�,��. Dafe 9- ��. ��__ � <br /> _ _ <br /> 1 <br /> i <br /> I <br /> 1 <br /> I <br />