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Froo: 10l26l2015 11 :34 p790 P.0031003 � <br /> l <br /> f <br /> � <br /> ` <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: � �A /l ►�n�, l'�LV �l�' . <br /> InstallalionAddress _� 611�. •�_ <br /> City' -G�.� tr'C-},L._ State:�_Zip:�� <br /> Mailing Address(rl difterenf): CKC/!1� <br /> Gity State: Zip: • <br /> [mal: ` ��A.11�{C��'►'�QI � ,Com Phone:� ���— fi <br /> 7otal Cost to Install Uevice{kom contractor invoice):S���' 00 <br /> i <br /> Ploase verify the following: <br /> �I am ihe owner of Ihe property where!he backrrater prevention device�vas installed. ' <br /> � I urorked with the contiactor to determine the tocation(or Ihe back.vater pre�+enUon de��ce and <br /> understand that!he deci,ir,n reyarding the IncaFon of Ihe device was mine. � <br /> [� My co�d�actor inslmded me how to access, inspect, and malnlam Ne device. <br /> i <br /> � I unders47nd�hal I am responsible for maintalning Qie back+vater prevenGor,device and keeping . <br /> it in good work�r,g ordcr, unless it is installr.d in Ihc cily righ,-of-tiray. <br /> � If I sell my property, I wiil make potenhal buyers a�tiare oF the bachvater prevenUon de�ice and <br /> the need tn inspect and maintain d cn a re�ular b�sis <br /> vI am enciosing ali of Ihe necessary paperrvork(use Ihe yellow Rebate Submillai Checklist). r <br /> i <br /> SHect trom tfic lollowing: , <br /> I <br /> [� The cc:dracror identified dovmspouts or other diainage Ilines lhat were connected lo my sewer <br /> Iine(hetween my house and the inslalied device)and removed,or remuted Ihem. ' <br /> I <br /> ❑ lo my knowledge, my property hus�n downspouu orothc dralnage connected to my sev+er line ; <br /> (bet���een my house and the installed device). <br /> rJ There are downspouls or othcr droinage lines connected to my sewor hne(bclwcon my howe <br /> and the!nslalled dewce), I understand that leavin,y these conneclions ueates a nsk ot Ilooding <br /> and I acccpt that risk. ' <br /> Sipnatuir . � Da[e�_� J <br /> � " I <br />