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� - -- - _. ___ <br /> I •�:• <br /> i <br /> I <br /> : Backwater Prevention Device Rebate Program <br /> 'i Rebate Application Form <br /> i <br /> ' Property Owner Name: �'�aCk �foWc�.Cf <br /> InstallalionAddress: (D2X �o�/�tdcl�t� f�✓C <br /> Cily: �✓rff{'�' State: �✓" ----_- Zip: Q�2vJ - - <br /> Mailing Address(if dillerent): <br /> ; City: State: 2ip: <br /> Email: -- Phone: (y� 3yS-37v� <br /> I <br /> � Total Cost to Install Device (lrom contraclorinvoiceJ: � � 77�bT <br /> � <br /> � -- -- — -- - <br /> Please verify the following: <br /> �, I am the owner of lhe property where ;he backwater prevention device was inslalled. <br /> �' I worked with lhe contractor to determine the location (or the backwater prevention device and <br /> understand lhat the decision regarding the localion of the devica�1as mine. <br /> il <br /> � My contraclor instructed me hotv lo access, inspect,and maintain the device. <br /> ' I undersland thal I am responsible for maintaining the backwaler prevention device and keeping <br /> � il in good working order, unless it is installed in the city right-of-way. <br /> � If I sell my property, I will make polential buyers aware of the backwater prevention device and <br /> I � lhe need Io inspect and maintain it on a regular basis. <br /> �, �j I am enclosing all of the necessary paperwork (use the yellow Rebale Submiltal Checklist). <br /> Tti <br /> �, Select from the following: <br /> � �The conlractor identified downspouls or other drainage Ilines Ihat were connected lo my sewer <br /> ' line(between my house and Ihe installed device) and removed, or rerouled them. <br /> , �To my knowledge, my property has no downspouts or other drainage connected to my sewer Iine <br /> (behveen my house and lhe installed device). <br /> I �There are downspouts or other drainage lines connecled to my sewer line(between my house <br /> and the installed deeice). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Signature �rG�/��''�/� _Date �Z Z / <br /> i <br /> � <br /> I <br />