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i <br /> ! �,�}� Backwater Prevention Device Rebate Program <br /> i �'�� Rebate Application Form <br /> "�'J-- <br /> � <br /> j —----- <br /> i <br /> i Property Owner Name:_1�o��_�psly�nS <br /> � <br /> � Installation Address: \u.2Z t�t��kc�- I�te _ __ _ __ <br /> I <br /> ; Cily:��e�c_�- Sta�e: W� Zip: ��j2D\ <br /> I <br /> Mailing Address (ildiKerent): <br /> , City: State: Zip: _ _ � <br /> � <br /> Email: Phone:(3�) �-��•�- f <br /> I <br /> Total Cost to Instatl Device (from confractor invoice): �_��O� <br /> Please verify the following: <br /> ; [i]I am the owner of the property�vhere the backwater prevention device was installed. <br /> i f7f I worked with the contractor to determine the location for the backwater prevention device and <br /> understand Ihat Ihe decisian regarding the location o(the device was mine. <br /> I <br /> i �My contraclor instructed me how to access, inspect, and mainlain lhe device. <br /> ' p�l understand that I am responsible for maintaining the backwater prevention device and keeping <br /> I' it in good working order, unless it is installed in lhe cily righl-ot-way. <br /> �If I sell my property, I ivill make potenlial buyers aware of the backwater prevention device and <br /> ihe need to inspect and maintain it on a reguiar basis. � <br /> � �I am enclosing all ot the necessary papenvork(use Ihe yellow Rebate Submittal Checklist). <br /> �i Select irom the following: <br /> ❑ The conlraclor idenlified downspouls or olher drainage Ifines lhat wr.re connected lo my sea�er <br /> line(between my house and lhe installed device) and removed,or rerouled Ihem. <br /> ❑ To my knowledge, my property has no downspouls or olher drainage connected to my s�wer li�e <br /> (between my house and lhe installed device). <br /> � � There are downspoids oi other drainage lines:onnected lo my sewer Iine(between my house <br /> and the inslalled device). I imderstand that leaving lhese connections creates a risk of flooding <br /> and I accept thal risk. <br /> i <br /> i <br /> I r1 <br /> Signature ��0���c���� Date Z � �"t <br />