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� <br />Backwater Praventiori De�Bc.e Re�ate Program <br />Rebate Applicatio� Form <br />r, <br />Properiy Owner Name: . <br />c.0 <br />InslallationAddress: L � ��b� 1<oG�Ca Q11(�� <br />� <br />City: � Y"✓ � Slale: L- �i� Zip:__) 1 <br />Mailing Address (il dilierenQ: � I n D J �� W / �U' � _ <br />Ci�y: ��-- Stale: LAY� ,Zip: � — <br />1�1� � -- <br />Email: Sl,��d�-,�11��o��L �i-b�m.;.i_cai.. <br />7otal Cost to Inslail Device (huro contract�r invoice): $ <br />Phone:(4�) �ba'�SSI <br />Plaase veri(y the fo�lowing: <br />� I am lhe owner oi lhe property where the backwater prevention device was instalied. <br />� <br />[J I worked with the contractor to delermine lhe localion for the hackwater prevenlion device and <br />u�derstenA Ihnl ihe docision regarding the Iocalion of Ihe device was mine. <br />��] My contractor Instructed me how to access, inspecl, a�d malnlain the device. <br />T <br />�I understand thal I am responsitde for maintaining the backwaler preventi�in device and keep�ng <br />fl in good workinc� order, �:nles< it is inslalled in the city right-ol-way. <br />�I( I sell my prcp�rty, I will muke pofential buyers aware of Ihe backwaler prevention Aevic.� and <br />lhe need to inspecl and meinta�n il on a regular basis. <br />v~fl] I am eecla�ini� all of Ihe nenssary paprnvork (use the yellnw Rahatr Submlttai Cher.klisl). <br />1 <br />Seler.! irom the Following: <br />—`'�]. 7he : ontrar.lor idenlified downspouts or alher dr�ainage Ilines Ihal wcre wnneated lo my sewer <br />line (Uelween my houss and Ihe inslalled device) �nd removed, or rerouled them. <br />� i n my knowleJge,'my property has no dcwnspe�ls or olher drainoge connected lo my sewer Ilne <br />�(hetween my house anA Ihe instalted dnvica). <br />(hei.^, aro downspouts or olhar drriinngo lines connec�ed lo nry sewer linu (between my house <br />and the insta�l�d dovice). I undersland that loaving ihosc connoctions creales a risk of Ilooding <br />and I aaept that risk. <br />�_� _. ��- __ <br />Signature� _�.._!�'c� l- -- - -- . _ . _ Da(o.._ <br />. r---. <br />