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@OBack-usa>ftr Pimvention Device Rebate Program <br />rr Rebate Appfi aUon Pura <br />Property Owner Name: IC'r7L`1 i_� :' 117E <br />Installation Address: <br />City: Sty: Tp: C - 1 <br />MaTnc Address (if dMiiveat): <br />Ci"y: <br />State: Yip: <br />Email: Phone:( <br />Total Cosi to install Device (r1 Ja confraciorinvcice): $ Z-1 0/ <br />l.' <br />Please ve:01Y the following: <br />w I am the ovmer of the property where ;he backwater prevention device was installed. <br />0 I worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the localton of the device was mine. <br />Pfilly contractor Instructed me hots to snows, Inspect, and maintain the device. <br />U I understand that i sm responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unlessIt is Installed In the city right-of-way. <br />Pit I sail my property, I vg11 make potei'W buyers aware of •Ste backwater prevention device and <br />the need to Inspect and maintain N on a regular basis. <br />I am erclesirrg all of the necessary papenwork (use the yellow Rebate Submittal Checklist). <br />SeIeL't from the foliow:Eng: <br />VrWNI <br />lThe contractor identified downspouts or other dralnage Ilines that were connected to my sewer <br />ine (between my house and the installed device.) and removed, or rerouted them. <br />To my knowledge, my property has no downspouts or other drainage connected to my sewer rine <br />�r (between my house and the Installed device). <br />There are downspouts or other drainage lines connected to my sewer line (between my h^use <br />and the installed device). I understand Neat leaving these connections creates a risk of flooding <br />end I accept that 14sic. <br />Sigraf�re' <br />