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i ' ' <br /> I <br /> � <br /> � Backwater Prevention Device Rebate Program <br /> � � Rebate Application Form <br /> � Property Owner Name: 1Y1 i G!f �� � � Sid7C—�2 <br /> � Installation Address: 13 Z Z /`U C �L rr /L- /�V� <br /> Ciry: rv P,�e'Y� state: ,/lJ� ZiP: �zr o�� � <br /> � Mailing Address(if diRerenf): tl � �. b�1C (c� 3 7 <br /> City: Ly�uNWoot�- State: `/V/g— Zip:���� <br /> ! Email:�i'_y2nNfrb�EaZ�1l�, Cm�/l Phone:(�Iyj �7/ '3(o /S <br /> � <br /> i <br /> � Total Cost to Install Device (Irom contractor invoice):S �' �8�• Q� <br /> � <br /> i <br /> i please verify the following: <br /> � �m the owner of the property where the backwater prevention device was instalied. <br /> I �worked with ihe contractor to determine the localion for lhe backwater prevention device and <br /> � understand that the decision regarding the location of the device was mine. <br /> I [�My contractor instrucled me how to access,inspect, and mainlain the device. <br /> � �understand that I am responsible for maintaining the backwater prevention device and keeping <br /> i il in good working order, unless il is installed in the cily right-of-way. <br /> i <br /> Iif I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> I the need to inspecl and maintain it on a regular basis. <br /> 1 �am enclosing all of the necessary papenvork (use Ihe yellow Rebate Submittal Checklist). � <br /> Select from the following: <br /> j� The conlraclor identified downspouls or olher drainagc Ilines thal were connected to my sewer <br /> � Iine(belween my house and lhe installed device)and removr ',or rerouled them. <br /> i <br /> i �] To my knowledge, my property has no downspouts or olher d; age connected to my sewer line <br /> � (between my house and the inslalled device). <br /> I ❑ There are tlownspouts or other drainage lines connected lo my sewer line(behveen my house <br /> and the installed device). I understand thal leaving lhese connections creates a risk of(looding <br /> and I accept that risk. <br /> � � �.� <br /> � �� � <br /> i Sfgnature_ ��L���Xf __��Date Z ' � — <br /> i � <br /> ,i <br />