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Y <br />.. _. .^�".. ��.�..��� ........ . ....� ._ ........__...� __..._... ..�..... � . ...........� .�_��. _ <br />� , . `.. . . . . <br />r� :t • ' <br />',"� �. ' �,�� Backwater Prevention Device Rebate Program <br />� � .�w�,.._, Rebate Application Form <br />.�«�, <br />n <br />e <br />n <br />A <br />Property Owner Nama_�% <br />Installation Address: <br />Cily: <br />Mailing Addresc (N dilloroni); <br />Clty: <br />Steta: <br />Slale: <br />:� � <br />r <br />Email: Phone:r(1`-1-r�,_`Jl�/ � <br />i <br />Tot21 C(isl to Install Device {Irom ccntrnctor invoice): S•• ' S nC� � <br />�� <br />Plcase varl}y tha following: <br />['�' I am the owner of the property where the backwater preventlon dewce was instalied. <br />J�I wcrked w�lh lhe conlrac;or to determine :he Iocallon for Ihe backwater proven6on device and <br />understand thal the decision regarding lhe localion of the dsvice was mine. <br />(x My contractor inslructed me how lo access, inspect, and malnteln the tlev�ce. <br />T <br />� I underslard U�at I am responsib�e for maintaming the backwater prevention device and keeping <br />It in good tiwrking order, unless d Is tnstalleA in lhe city nght•of-way <br />� If I sell my propeRy. I�vlll make potenllal buyors aware of ihe backwater preven(ion devico and <br />the need lo Inspect ond malntain it on a roguler basls. <br />� I am enGusiny all of lhe nucnssaiy paperwork (use tite yellav Rebete SuDmittal CneckllSq. ., <br />Seloct Irom the following: <br />7he conlraclor identlfied downspouts or other dramage Iiines that were conaectetl to my sciwer <br />s w <br />li�e (beN�een my house and the installed device) and remo�ed, or rerouled them. <br />�To my knaxfedge, my property has no downspoufs or nlher dreinage cnnnected lo my sawor line <br />(between my house and the inslalled devico). <br />�J There are downsooul5 or olher drainage lines connected to my sewsr Ilne (beRveen my houSe <br />and the Ins�alled devicv). I undoretand thal leaving thcse connoctions createn o nsk of Ifooding <br />artd 1 accept Ihat risk. <br />Slgnafuro `�n/�� 1-� �^ Deto :? - � � " �:J <br />0 <br />i_ _ _ (__ . _. _ . __�_. .. '�-"- -' -.•-..._..: -_'-' <br />