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I . � <br /> � <br /> i <br /> � Backwater Prevention Device Rebate Rrogram �� <br /> Rebate Application Form ; <br /> Property Owner Name: i�C���hi ��nl� � <br /> Inslailalion Address: /� Z z /��«FP;- flL•'P/zu � � <br /> / 1 i <br /> City: �i1:�4P(/ __Stale: �(JF� Zip; ���f��� ; <br /> I <br /> h9ailing Address(if dilferenfJ: ' <br /> City: State: Zip: � <br /> � / -- <br /> Email: /�� /J�h•'� ri�J,�(., c�rl��J.C'c'n? Phone: (�{1� -fS7� hOJ'/ <br /> j <br /> Tolal Cost to Install Device(lrom confractor invoice): S i <br /> i <br /> Please verify the following: . <br /> �I am lhe o�vner of the property where the backwater prevention device was inslalled. <br /> � I worked with Ihe contractor to determine Ihe localion for the backwaler prevention device and <br /> undersland lhat lhe decision regarding lhe location of the device was mine. <br /> � My conlraclor insirucled me how to access, inspect, and maintain the device. i <br /> �'I understand thal I am responsible for maintaining the backwater prevention device and keepiny <br /> Il in good working order, unless it is installed in Ihe cily right-of-way. ' <br /> �� If I sell my property, I wiil make polential buyers aware of Ihc backwater provention device and ! <br /> Qie�ced to inspect and maintain il on a regular basis. ' <br /> �I am enclosin�all of Ihe necessary papenvork (use the yellow Rebate Submiltal Checklist). , <br /> � <br /> Select from tho (ollowing: ' <br /> ��The conlraclor identified downspouls or olher drainage Ilines Ihat were connecled to my sewer <br /> �I'ne (hr.tween my house and the inslalled device)and removed,or rcrouted them. <br /> b my knowledge, my property has no downspouls or othe� drainage connected lo my sewer line � <br /> (belween my house and Ihc installed device). <br /> ihere are downspouls or other Arainac�e lines cunnecled lo my sewer line(belween my house �' <br /> �. `\ �nd tho installed c�evi ). I unAerstand ih�it Ic�viny lhese connections creates a risk of Oooding i <br /> Ilv and I accepl th risk� <br /> � � � <br /> / / . <br /> ��,�i � - - , � � <br /> Signature Date � <br />