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Backwaier Prevention Device Rebate Program <br />,, �tebate A�plication Form <br />� <br />i \/ �� `� 1� <br />�, Propeny OLvner Name: •� � ��'�'+��L-L� '� .�N���U�" Q�� <br />Installa�wnAddress: Z�����- k ���-�� �-�� �_ __ <br />City: _L �� �%:� _ State' �'J�1 <br />�vlailing Address (if dil(erent) _ <br />City: State: <br />Zip._ � � ��O � <br />Zip: <br />Emad: KC�.COVLI OK C� �'LCy��A-t` , L�l„�Phone: r��� ��� Z G1`�i�E �. <br />Total Cosl to Insfall Device (lrom confracror invoicel: S������ __ <br />Plcase verify the fotlowing: <br />[�� I am the osvner of Ihe properly v�here the backwater prevention device was inslalled. <br />`✓ l �vorked �vith the conlractor to determine 1hF location for the back�r�a�er preventiun device and <br />understand that the decision regarding the Ic..alion of the device v:as mine. <br />,•-� My conUactor instrucled me how b access, inspecL and maiMain the device. <br />f•-�' I understand,Uiat I am responsible (or maintaming the back�valer prevention device and keeping <br />` �f in yood �vorkiny order, uNess it is installed in the cily right-o(-�vay. <br />�� '"�If I scll my properly, I will make potenti ;I buyers aware of the back�valer prevenlion device and <br />lhe need to inspecl and rnainlain it on a regular basi5. <br />I�J' I am enclosing all of the necessary paperwork (use the yello�v Rebate Submittal Checklist) <br />Select from the followiny: <br />�; The wntractor identified doemspouls or other drainage Ilines lhal were connecled to my se�ver <br />line (bel�veen my house and lhe inslalled device) and removed, or rerauled lhem. <br />(� To my knowledye, my property has no downspouts nr other drainage connected lo my sewer line <br />(behveen my house and ihe Installed device). <br />j� There are downspouts or other dramaye 6nes connecled to my sewer line (behveen my house <br />and lhe inslalled d� cice). I undersland that feaving these connections crea�es a risk of flooding <br />and I accept ihal risk <br />� ,,i�� ( � ���( � <br />Signatures=__"'����"`��`j` - Dafc��_�"1 ��1-� <br />,� <br />