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� <br /> i <br /> Backwater Prevention Device Rebate Program � <br /> ��%?� Rebate Application Fo'rm i <br /> i <br /> i <br /> II Pro yp rtc Owner Name��P P�i�\�_�Cr E"7 I i <br /> InstallationAddress: D� G � �i� � <br /> City:_G_5;��_State.�_Zip��� ` <br /> � <br /> Mailing Address(il diNerenq: � <br /> ��I City: State: Zip: ' <br /> Email. Phone: (� .�l.�i� ��(� I i <br /> i <br /> Total Cost to Install Device(Irom contractor invoice): S ����•�c� � <br /> � <br /> Please ve�ify the following: ' <br /> i <br /> dl am the o�vner of the properry where the backwater prevention device was installed. � <br /> [,J"1 worked with the contractor to determine the location 1or 1he backwater prevention device and ; <br /> understand that the decision regarding the location of Ihe device was mine. <br /> [� My contraclor instructed me how to access, inspecl, and maintain the device. ' <br /> �� I understand thal I am responsible for maintaining the backwater prevenlion device and keeping ; <br /> it in good working order, unless it is installed in ihr_ city right-o6way. ! <br /> i <br /> [J Ii I sell my property, I will make potential buyers aware oi the backwater prevention device and <br /> the need to inspect anA maintain it on a regular basis. j <br /> : <br /> [� I am enclosing all of 1he necessary papenvork(use ihe yellow Rebate Submidal Checklisl). <br /> Select from the lollowi�g: ' <br /> [J The conlractor identifed downspouts or other dramage Ilines that were connected lo my sewer � <br /> linc (belween my house and the installed devlce) and removed,or rerouted them. <br /> ! <br /> [,�To my knowledge, my property has no downspouts or other diainage connected to my sewer line f <br /> (between my house and lhe installed device). <br /> (—j There are downspouts or other drainage lines connecled to my sewer line (belween my house , <br /> and the installed device). I undersland ihat leaving these conneclions creates a risk of flooding <br /> and I accept lhal risk. <br /> � � . / <br /> � /I i <br /> Signature� � �• / Date�) — ������.1 f � <br /> � <br /> � <br />