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Backwater Prevention 'DC�;on Forme Program <br /> Rebate App <br /> Property Owner Name: QI/ <br /> �LPn�� �n �U�aS�ev�,� I�tG�/ / t� ��V <br /> Installation Address _ 2 J � � �I I'�' UT__ p <br /> ����Y �i�1' State: vU—/—Zip: 0 2� <br /> Cily: _ <br /> Mailing Address (if diKerent): <br /> �S'GLS'Vl li �---- <br /> I State: �—Z'N' <br /> • c�y —___--`.�--- 201� qg3,22u(e.. CK �h) <br /> � KF.Vrl1� UQ��r���SO�� . C01'VI _Phone: ( <br /> Email: _ �/�,�1 :g � <br /> � `f <br /> . Total Cosl to Install Device (Irom contractor invoice): 5 <br /> � Please verify the following: <br /> � I am the owner oi lhe propertY�vhere the backwater prevention device�vas installed. <br /> � I worked with the wntractor to determine lhe location for the backwater prevenlion device and <br /> understand thal the decision regarding the localion of the device�vas mine. <br /> i <br /> Ull My contractor inslructed me ho�v to access,inspect, and maintain the device. 1 <br /> .�.� <br /> I understand Ihat I am responsible for maintaining lhe backwaler prevention device and keeping + <br /> � il in good working order, unless it is inslalled in the city right-ot-way. <br /> � If I sell my property, I will make potential buyers aware of the backwater prevenlion device and <br /> the need to inspeol and maintain it on a regular basis. <br /> 1 <br /> i Q�j I am enclosing all ot lhe necessary paperv+ork(use the yellow Rebate Submittal Checklist . <br /> 7� <br /> • �Select from the following: <br /> i <br /> i � The contractor identified downspouls or olher drainage Ilines lhat were connected to my sev; <br /> ' line (between my house and the inslalled device) and removed, or rerouled lhem. <br /> i <br /> � �] To my knowledge, my p�ope�y has no downspouts or other drainage connecled to my sewei me <br /> � (between my house an� lhe installed device). <br /> �� � There are downspouls or other drainage lines connected to my sewer line (behveen my house <br /> and the installed device). I understa�d that leaving these connections creales a risk o(9ooding <br /> ' and I accept that risk. <br /> , % <br /> , ; , G, q. �� <br /> , r �Date <br /> Signature ` <br /> j <br /> ( <br /> i <br /> 1� --. . _ - –'— -- ' — _ I <br />