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Backwater Prevention Device Rebax�� Prograrn <br />Rebate ^pplication Forni <br />PropeAy O��mer Name: I`� �ke��'4r V 2- � ��- <br />Installation Address: � 6 �� 2o�ke�/1� �JVP. � � _ ._ _ <br />City: Eve!?� State: ��_ Zip: g'��1 <br />Mailing Address (il diHerent): �7�3 �. �l i5'� /� vt, l� � <br />city: (�(c.e, i"j�(e s-� Pc�✓k state: �� <br />R8�( SS <br />Email:_ 6LkGtVe� �'i��al�•COwt _Phonei(415�`�7t-67�? <br />Total Cost to Inslall Devic= (from conrrector invoice): 5 ��19 �O. 3 f <br />G1a la Yja�3 tVFk�o.o� eµ�•u✓ <br />Please verify the followfng: ,��� �r54 �3 <br />'j1�,�w- �r+, <br />[J�I am the o�+�ner of the property �vhere the backwa:�r prevenlion device e�as installed. k„„�,� <br />ti""� <br />[v� I worked with the contractor to determine ihe location for the backwater prevention device and �� h/�r <br />understand that the decision regarding the location of the device was mine. <br />[�7 My contrac:tor instructed me how lo access, inspect, and maintain the device. <br />[�I understand tha' I am resoonsible for maintaining ihe backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-oi-caay. <br />; v7 If I sell my property, ! will make potential buyers a�vare of the 5ack�vater prevention device and <br />the ne2d to'nspect and maintain It on a regular �iasis. <br />[�I am enclosing ail of the necessar� paperwork (use the yellow Rebate Submittal Checklisl). <br />Select irom ttte following: <br />U The conlractor identified downspouts or other drainage Ilines Ihat were connected !o my se�ver <br />line (belweec my house and the installed device) and removed, or rerouted them. <br />[v� To my knowledge, rry property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). � <br />❑ There are do�vnspouts or other drainage lines connected to my sewer line (between my house <br />and Ihe �nstalled device). I undersla�d lhat leaving Ihese conneclions creates a risk o( ilooding <br />and I accept Uiat risk. <br />Siqrtature /��1�YA- �' Dafe //-�n -�S _ <br />