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i <br /> ! Backwater Prevention Device Rebate Program <br /> , Rebate Application Form <br /> i <br /> � <br /> � Property Owncr Name: �l I!1 A t't , u�I e.✓ <br /> ; in:;allation Address: _��v��u �1e e�P� V8 <br /> I /� <br /> City: I—;VPrP� _S�ate:��_i:ip:��� <br /> Mailing Address (if diNerentJ: <br /> �� Cily: Stale: _Zip: _ <br /> � EmaiL�le✓ � G!M[!II,�N7 _Phone: (N�.��17-0774' I <br /> j � I <br /> � Total Cost to Install Device (fro,ro contractor invoir.e): $ e��J�Q�� __ <br /> i <br /> Please verify 4he following: <br /> II am the owner of the property where lhe backwater prevention device was installed. <br /> �rked viith ihe contractor to determine the localion for lhe backwater prevention de�ice and <br /> � understand that the dec.sion regarding the location of ihe device was mine. <br /> � ��contractor instructed me how lo acces inspect, and maintain the device. <br /> �I tnder5tand that I am responsible for maintaining tBe backwater preveMion device anc�keeping <br /> ' it in good working order, unless it is installed in the city right-of-way. <br /> i � <br /> � 0'lf I sell my property, I will make polential buyers aware of the backwater prevenlion device and / ! <br /> I the neeo to inspect and maintain it on a regular basis. _ wll' ��op p�',F' (,1/-L� c,o�m✓a/�/`r <br /> I � / <br /> � �am enclosin� all o(the recessary papenvork(use Ihe yellow Rebate Submitlal Checklist). <br /> �i Setec2 from the following: <br /> I ❑ The contraclor identi(ied downspouts or olhcr drainage Ilines that were connecled to my sewer <br /> � line behveen my house and the ins;alled device) and removed, or rerouled lhem. <br /> � • o my knowledge, my property hss no downspouls or olher drainage connected lo my sewer line <br /> (belwe�n my house and the inslalled device). <br /> � ❑ There are downspouts or olher drainage lines c:onnected lo my sewer line(between mq house <br /> Iand Ihe installed device). I understand thal Ieaving lhese conneclions creates a risk of(looding <br /> � and I accepl that ris <br /> � <br /> I � <br /> � Signature Date � 7 �`� <br /> � <br /> I <br /> I <br /> I <br />