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����� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> � ��,--� � <br /> Property Ovmer Name: ��-'�/h� �• � e� <br /> Installation Address:�i��y/J. U�l�/� � �.�� <br /> ���, / ,� <br /> City: �[/ i,��'�,fi State:_�,�Zip: iJG-'���� <br /> Mailing Address (if diHerenQ: <br /> City: �, State: Zip: <br /> Email: ���( �=L � (��Q '�r+none: ( � � ��S o�-— S S� <br /> Total Cost to Insiall Device ((rom contractorinvoice): 5 � SGG./ <br /> Please verlfy the following: <br /> � m lhe owner o(the propeAy where the backwater prevention device was inslalled. <br /> 1� <br /> I �vorked with the conlractor to delermine lhe location for the backwaler prevenlicn device and <br /> understand that the decision regardmg the location of ihe device was mine. <br /> i �i( my contractor instructed me how to access, inspect, and maintain lhe device. <br /> tr- <br /> �understand that I am responsible for maintaining lhe backwater prevention device and keeping <br /> ��� d in good working order, unless it is installed in lhe cily right-of-way. <br /> ..�--- — <br /> �I sell my property, I will make potential buyers a�vare of ihe backwaler prevention device and <br /> t�he-need lo inspect and mainlain it on a regular basis. <br /> �� am enclosing all of the necessary papervaork(use the yellow Rebale Submitlal Checklist). <br /> Select from the followi�g: <br /> � [�'The coNractor identified downspouls or olher drainage Ilines that were connected to my sewer <br /> V line (hehveen my house and the installed device) and removed, or rerou�ed them. <br /> ❑ To my knowledge, my property has no downspouls or olher drainage connected lo my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines conneGed to my sewer line (be�veen my house <br /> and lhe installed device). I understand lhat leaving these connections creales a risk of flooding <br /> and I accept lhat risk. <br /> �� <br /> , , <br /> ,,... , � <br /> ilI" <br /> Signa re "� '�"� � � Cid�( Date ��0'1�•'�� � �Li�S <br /> � <br /> l�.--- " <br /> I ---_ _ _ -- — _ _. — -- � - -- <br />