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i <br /> � <br /> ; <br /> ; <br /> i <br /> � Backwater Prevention Device Rebate Program <br /> Re6ate Application Form <br /> PropeRy Owner Name. � � �- �rSon <br /> Installation Address <br /> City:—L f��State:_ W�Zip: �� <br /> M17ailing Addross(il diHerenlJ: <br /> City _ SWIe: Zjp; <br /> Emall: Y�SS�R�are P_.s7'[�l�� . neT �Phonc:�.Kj 3�1 /q <br /> D <br /> Total Cost io Install Device(from contmctorinvorceJ:g <br /> L_ <br /> Please verify th�}oilowin8: <br /> � I am the owncr of Ihe property where ihe hackwaler prevention device was installed. <br /> ❑ I worked with the confraclor to determine Ihe locetion for lhe backwater preveNlon device and <br /> undnrstantl Ihal the tlecislon�egerdln�ihe IoraGon af Ihe davice was mine. <br /> ❑ My eomraqor instrucled me haw to access,inspect,and malntain the dovice. <br /> �] 1 undcrsfand that I am msponsibie for malnWining lhe beckwater praventlon dnvice end keeping ! <br /> it In gaod working order, uniess Il Is inslalled in Ihe city righbaf•way. <br /> i <br /> � If I sel�my proporty, I wi��make palentlal buyers aware of the beckwate�preaention Covice and � <br /> Iha need to Inspect end maintaln it on a regular basls. ' <br /> m I am enelosing ali of the necessary papervrork(use tho yellow Hobata Submittal Checklist). ' <br /> Select from the kllowln�; � <br /> ❑ T�a cnntreclor ldenGfied downspouts or oNer drainage Illnes thal wera connecled lo my sewer � <br /> Ilno(betyyeen my hnuse antl the installud devi�c)and removed, or remutetl Iheiri. <br /> �} To my knowlcdge,my propxrry has oo downspouts or othet dr�3U�ngp cppneclCtl t0 my Sewer lino <br /> (6r.pveen my hausc�nd�he inslallcA tlovice). <br /> ❑ Theie are downspouts or olher drainage lines connecled lo my sewer Ilne(between my house <br /> and ihe installod devlCe). I unOersiend lUat leaving t�esQ connnrtions troales a rysk of OooCinB <br /> and I aaopt Ihat riak. <br /> i <br /> S7gnature��^—'L'�i ^"�'"� Date / �� /r" '' <br /> I <br /> i <br /> S�S��bpd TO£b 652 S3b�wa�J 90�L"T SS63-82-Ntif � <br />