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Backwater Prevention Device Rebate Prograns <br />T, Rebate Application Forrn <br />� <br />Property Ovmer Namefs'P �^ T 5 l�un q z � G�+ <br />InstallationAddress: %(�l f�bc-i��<-���r�� • <br />Cily:��¢Yd't{' State: Wf� Zip '�8�'p� <br />Mailing Address (ildifterent): I� S�'J� �� ��Ve . G1/E <br />c�cy:lAke,Fer�.s-� av Stale: ln�ft zip: `1$(SS <br />Email: rd GIC a ve °� W1Q I I•� bv� •Phone: (�Zy� ���— 6� f � <br />Total Cost lo Install Device ((rom contractorinvoice): S ! y9 S•.5 O <br />— - �V, ''° 'I"`� Vrb 1`�/�+t a..n.v.r <br />Please verify the following: `� <br />'1l-wti �rr, <br />✓rA� <br />[✓ I am the owner of the property �vhere the bacfavater prevention device vras installed. ���� � N,Spp <br />[✓]� I worked with the contractor to determine the lo^ation (or the back�vater prevention device and t �/� f 7� <br />understand that the decision regarding the IocaGon oF the device was mine. <br />[� My contraclor instructed me ho�.v to access, inspect, and mainlain the device. <br />[,�" I undetstand that I am responsible for mainlaining the backwaler preve:ntion device and k@eping <br />it in good working order, unless it is instailed in th� cily right•of-�vay. <br />�' if I sell my property, I will make potential buyers aware of lhe backwater prevention device and <br />the need to inspe�t and maintain it on a regular �iasis. <br />Q�I am enclosing all of the necessary papenvork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage Ilines that were c�nnected to my se�ver <br />tine (between my house and the installed device) and reinoved, or rr.routed them. <br />[�To my knowledge, rny property has no downspouts or olher drainage connected to my sewer line <br />(behveen my house and the installed device). <br />❑ There are do�vnspouts or other drainage lines connected to my sewer line (benveen my house <br />and th? installed device). I understand that lea� ing lhese connections creates a risk of 1looding <br />and I accept thal risk. <br />Srgnature � Datc /l-h'/.S <br />