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i .. <br />f <br />}' <br />�. <br />1 . <br />. �Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner fJame: _ � n � <br />Inclellatlon Address: �2) � � <br />Ciry;��'� Slale: <br />Malling AddreSS (rf diflerenU: <br />i //i��.�� <br />ziP:_ �� �� 1 <br />• � ; City: Slate. _____ Tp: <br />. . Email: Pnone. ( ' � �^23fi ••%3U <br />Total Cost to Install Devicc (lrom contracta involcej. 5 �_ ._ <br />Ploaso verffy ihe following: . <br />��, � I am the owner of the property where the 6ackwater pfevenqon devica was inslalled. <br />. T I worked with lhe contractor lo determine Ihe lo.alion for the backwater prevenlion device and <br />� underetand thal Uie decision rega�Jing Uie location of the devlce was mfne. <br />�. [�'My •�ontractor instructed me how to access, inspect, and maintain ihe device. ' <br />� <br />,� I understand that I am rca�ponsible for meintalning the beclnvelef preventlon device and keeping <br />�• It in cood working order, unlesa it Is Instelled in the cih .rightof-v�ay. <br />�, ��II I sell my property, I w111 make polentlal buyers aware of the backwaler prevention tlev�Ce and <br />. the need to inspect and maintein it on a repuler basls. <br />, .'. �I am encloiing all of the necessary paperwork (use the yellow Rebpte SubmiHol Checktist). <br />� ' � Select from tne Tollowing: <br />'❑, The contractor idenl�ed downspouts or other drainage Ilines thal were connected to my sewer <br />� • Ilne (beMgen my house and the inslalled device) and removed, or rerouted them <br />• To my knowledge, my property has no drnmspouts or olher drainago connected to my sewer line <br />�'�(between my house and Ihe Inslal4ed dovica). <br />' � There are downspouls or ullier Jrainage Ilnes connecled to my s�•Ner Ilne @etween my houae <br />�nd the installed device). I understand that leaviny lhese connec:lfons creates a nsk of Oooding <br />.. and I accept t�sk. • <br />: �� • , // . <br />� <br />� <br />� <br />�� $,gn � .t.� ��� �. ,C�-;�� os�.,�� IS' ' <br />� :. <br />m <br />a <br />