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i- - -- <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> ! <br /> Property Owner Nanie: ��q\ �h��y ! <br /> J IInstaUation Address: O� �c��l cxk�f�ll c� 1"lve. <br /> f.ity: �� «� � State: W� Zip; G'� Ol <br /> i — - — <br /> Alailing Address (il diKerent): <br /> , City: State:_ Zip: <br /> Email: _Phone:{��_Z.SR — 40 2�c <br /> I � <br /> Total Cost to Inslall Device (froTi con(2cfor invoice): S_Z e�g ' �9" __ <br /> i <br /> Please verify the fotlowing: <br /> �am the o�vner o(the property where the backwater prevention device was installed. <br /> [I worked with the coniractor to determine the location fo,the backwater prevention device and <br /> I understand thal the decision regarding ihe location of the device wes mine. <br /> , Q My contraclor instrucled me how lo access, inspect, and maintain the device. <br /> �understand that I am responsible(or maintaining the backwaler prevention device and keeping I <br /> il in good working order, unless it is instaUed in the city right-of-way. � <br /> I �f I seil my property, I will make potentiai buyers aware of lhe ba��water preven'.ion dewce and <br /> the need to inspect and maintain it on a regular basis. <br /> � �am enclosing all of tha r.ecessary papenvork (use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> i <br /> The contraclor identi(ied downspouts or ofher drainage Ilines Ihat were connecled to my sewer <br /> line (6etween my house and the inslallerl device)and removed, or rerouled them. <br /> �� [!f To my knowledc�e, my property has no do�vnspouts or other drainage connected to my se�var line <br /> i (bclween my housc and the installed device). <br /> ❑ There are downspouts or olher drainage lines cnnnected to my sewer line(between my house <br /> and the instailed device). I undersland that leaving these conner,tions creales a risk of floodmg <br /> � and I accepl lhat risk. <br /> i �_ <br /> i c / I <br /> I Signature Date /Z�/-7� � <br /> i ' <br /> i <br /> I <br />