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Mar l3 15 07: 14p p•2 <br /> � Backwater Prevention Devic9 Rebate:Progrem <br /> Rebate ApRlication form <br /> i�� J�....... ,,.. ... —� <br /> Property Ownflr Name: _J G�v� � . �4 C. �.eu� � <br /> InshdVationAddres9: I � 3 / � �CC.��C� u <br /> c�,; �'Ntv� s,e�e: wl�,z�N: 5'P��l <br /> iMailing Addres5(it adlerer�- <br /> Clry: State: Zip: <br /> � Email:,1�4C=�B�iU�S�L7r GIl ,GEi�Y� Phone:(7�J� �-S�4r/1-� <br /> Totel Cost to Install Device(hom confractorinvoic�):$ �y �� �•�� <br /> L--- -- ----� <br /> r�eaae ve►ny nie ra�ow�ng: <br /> � I am Ihe owner oi tlie proparty ivliem ihe badavater prev¢rttbn deWce wec Inslalled. I <br /> 'F� 1 wdiiced w8h the oontrectot t0 tlatermf�e l.he locntion{pr the beckwater prevenllon device end <br /> T� undersWrtd that the decielo� regarding Uie location ailhe device was in(ne <br /> �j My_conGecEor.instructe,i me how to xcess,iospep,aid�maintdlo the de�rc�a- - _ _ _ _ _ . . <br /> �] I undersland Ihat I em iesponsible for mainWiniag 1he backwaler preventan device and keeping � <br /> it In good waricing ordeT:vnless it Is Inslalled in Ihe dty'rigM-oRway. � <br /> �] If I sell my property,l wUl make potential huyers eweie oithe 6ackweter provention device and <br /> tha need to i�pect aed RrainMln ft ati e regular Gasis. <br /> �J t am onGosing all ot the necessary papenvork(use t�e yellow Rebate Submlttal Checktiet). <br /> select ftan the tolbwing: <br /> � The Contractor ldenUfied downspouls or other dreinage�Nqea thet wero connecled to my sewe� � <br /> hne(hehvoen my house and the Inslelled dedice)and removed,a re�arted them. <br /> �] To my knowl8dge,my pmpariy has no downspauts or other drainega connected lo my sewer line <br /> �(betvreen my house end the installed de41Ce). <br /> Thete ere downspouts or other dralnage lines connactod to my sewer line{between my house <br /> and the instal{ed device).I under3tar�d Ihat teatiing ihese connnclions creafee a risk of flooding <br /> arni I axePt tnst ri�k. <br /> � n I <br /> Slgnafure "� � �'� . Date � !, � 5^ <br />