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� <br />� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Ovmer Name: �I a� r� � o r��y�-�e lQ {� �iCo c1c�%�(e.� <br />InstalfationAddress: 3`�D5 7uck�rz((�r L�..e .� <br />O <br />City: ��'Jz� State: �� Zip' Q g Z � <br />Mailing Address (il diNerenf) �''r� � I 4� /� „�c <br />S . ,.: <br />CIiY: .Y�. e. N"l r_ <br />Email: e�J "�O <br />St2te: � � <br />G.v�J� yv�y.l.Gu+- <br />9�rrog <br />Phone: (?1X-j 2Z4 - Z`�� � <br />Total Cost to Install Device (f�om contrecfor invoice): S'�'�'�� ���ss g� <br />Please verify the following: <br />[� I am the owner of lhe proper�y where Qie backwater prevention dewce :vas installed. <br />[�I �vorked r+ith the contrector to determine the location for the backwater prevention device and <br />undersland that Ihe decision regarding the Iocation of the device was mine. <br />�My contractor insiructed me i�rnv to access, inspect, and maintain the device. <br />�understand that I am responsib�e tor maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city righbof-�vay. <br />�� Ii I sell my property, I will make polenlial buyers aware of the back�vater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />0 I am enclosing all of the necessary paperwork (use the yello�� Rebate Submiltal Checklist). <br />Sefect from the following: ,µ,c �' �o� `+' �. L�' L��rrj <br />�y,�. v ,,••Y S,✓` .,� i� ,r. <br />[�The contraclor identified downspouls or olher drainage Ilines thal were connected to my sewer <br />line (belween my ouse an o ms a ed device) and removed, or rerouted them. <br />❑ To my knowiedge, my prnperty has no dowi�;pouls or other dreinage connected to my sewer linc <br />(betv.-een my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (behveen my house <br />and lhe i�stalled device). I understand that leaving Ihese conneclions creates a risk o( (looding <br />and I accept thal risk. <br />S/gnature �%�'�— ���•"`��"'C�— Date �-� ( � � � I � <br />