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O1/11/2010 18:29 1'EL 4259578657 <br />Backwater Preventlon Devfce Rebate Program <br />Rebate Appllcation Form . <br />Property Owner Name: <br />�� <br />Instellation Address: �1 b� �•bTl Yl.l£ ✓ D9'UE <br />City: � V.C✓��-1 State: �� Zip: ��- V� <br />Melling Address (i/diderentf. ,��K�rre <br />Gity: <br />State: <br />�oox <br />Zip: — <br />Email: ��.�8� elo��'m;�n.� �,�-� phone: (4� ,� 2�o fS-'i�Co 2 <br />Total Cost to Instell Device (Imm confracfoNnvolca): S Z-�-\ ��1 • 3� <br />� <br />Plaase ver(fy the following; <br />�y' I em the owner of tha praperty where ihe baekwater prevention davice was Installed. <br />�worked with the confraCtor to determine the location for the 6ackwater prevention device and <br />underatand that the decision regarding tha location of ihe device was mine. � <br />[�iAy conUactot instructed me how to ecceas, inapect, and maintain the tlevice. <br />�ndersfa.td thet I am responslble for mainteining ihe backwater proventlon devlce end keeping <br />it in good working order, unless it Is installed In the cAy right-of-way, <br />[�'�I sell my property, I wlll make potential buyers aware ot the backweter preventicn davice end <br />the need to inepset and maintaln it on a regular basis. <br />�I em enclosing aM of lhe �ecessery papeiworir(use the yellow Rebale Submlttel Checkllst). <br />V�- <br />Select from Me following: <br />� The contractor ldentified downspouts or other dralnage Ilines that were connected to my sewer <br />Ilne {between my house end the installed device) and removed, a rerouted them. <br />7o my knowledpe, my property has no downepouts or other dralnage connected to my sewer Ilne <br />(between my house and tha Instelled devica). <br />❑ There ere downspoufs or other dreinage linea eonnectetl to my sewer Iine (beM/een my house <br />and fhe Installed device). I undarstand that leavi�g lhese connections creates a risk oi flooding <br />and I accept that risk. <br />.:�i�f -;�%vi�Jf�'i irY .C, c 4 <br />�` I�o CC�I�D�� �� <br />11�1 NUI�?��:014 <br />PUBLIC WORKS <br />