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O1/14/2010 18:40 TSL 626�6T8887 <br />Backwater Preventlon Device <br />Rebate Appllcation <br />Property Owner Name: <br />�� <br />Rebate Program <br />Form <br />@�ooz <br />Inslailetion Address: �� b�� 12•6tl Yl.lf ✓ Dq'L� <br />c�ry: � v.e%e u sta�a; .tn9 eA z;P:_°Id'2 0� _ <br />Mailing Address (il dil/erenf): ,�,14,rre <br />Gity; <br />State: <br />Zip: <br />Emaih 1 ��'+ L' loi.7�'ry�.�. ',� Phone: (Qz� 2ro —�a� 2 <br />?^-�-\ 4� 4 • � � <br />Total Cost lo Install Device (from conhaqtorinvolceJ: S �- <br />Plsase verify the following; <br />� I em the owner of the property where the backwater prevention device wes Installed. <br />�worked with the contraCtor to determine the Iocetion (or the beCkwater prevantion device and <br />undarsland that th9 decision regarding the Iocation of the device was mine. <br />[�fuly contracto� instructed me how to axess, tnspect, and mainteln the device. <br />�nderstend thet I am re�ponslbie tor maintaining the backwater prcvenHon deviCe and keeping <br />it in good working order, unless It Is instelled fn the clty right-of-way, <br />Q'f I sell my property, I wlll meke potential buyers aware ot the backweter prevention device and <br />the need to fnepect and maintaln it on a reguler basis. <br />�I am enClosing ell of the necessery paperwork (use the yellow ReAate Submfttal Checkllst). <br />ur. <br />Select from the foltowinp: <br />� The contractor ldenHfled downspouts or other drelnage Ilines that were connected to my sewer <br />Ilne (between my hoUse and the install9d deviee) and removed, a rerouted them. <br />7o my knowledqa, my property has no downspouts or other dralnage tonnected to my sewer Ilne <br />(batween my house and the Insteiled device). <br />❑ There are qownspouts or othet drainege lines connected to my sewer line (between my house <br />and the Instelled device). I underetend that leaving these conneetions croates a risk eiflooding <br />and I acce�t that riak. <br />�� �����o��� <br />u�� NON ? � ?014' <br />,�/f-,�/v�%hr irY �,c 4 PUBLIC WORKS <br />