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_ _ _ __ _ _ _ ; - . - . -� , i <br /> . ..' . . �y� .,f� „ , ' i <br /> . �:..�n�� .�:--'r "r . „ii.'Y�r'�� �'!' it' n'f�e -.:a� �� �rk.. . . . ; 1 <br /> Backwater P�ev�.'ention Device Re�ate.Program � . <br /> � Rebate Applicafion`.Fo m � � �' <br /> � <br /> � ,. - :,. <br /> - - , <br /> t .., , . . , .. , . ; . <br /> � Property Owner Name: ' LlP,i0. L I V1(�E( '� �i ` �• � <br /> i , , , ' <br /> Installation Address: � $OS � t/�C,�C.� ��J�'� � � � � • . <br /> �.n _ <br /> City: �VQ,fQ.�}' Slate: V��.: Zip: vI:g20� <br /> i . . , ' �. ��. <br /> iMailing Address(il dillerentJ:_� � ., > ' <br /> i City: State: Zip; � , <br /> Email:,�l�o.r�d 0.f�U.��r�cVe,t'@_ �r'on�4iCf•�P e: �HZ� 319 - �s�'7�� � <br /> Total Cost to In'stall Device(from confractorinvoice):$ 2�.50� <br /> , ��:' ', • " '. <br /> i ,, . ,, ' . . . ��l ''b p� . �,�op ��� •.GW�el` ` ` �. <br /> ', � Please verify NeYollowing: ' <br /> fil.ro,,,� UT I `t 7 3.. �1�.� �o� '� (r��� �b� <br /> ' � I am Ihe owner of the property where the backwaterpreVentan;device was installeU. <br /> , . . .1�/. �4/i5. .. <br /> � 1 ivorked with the conlractor to defermine the location for the'backwater prevention device and ' , <br /> undersland that the decision regarding the taafion of the deJlce,,uvas.mine. ' � • <br /> ❑ My conlractor.inslructed me how to access,inspect;'and,maintein Ihe device. � • .• <br /> ❑ I understand thaCl am responsible for maintaining Ihe backwater prevention device and keeping <br /> iil in good working order;Unless it Is installed in.ihe city nghl;of-way,. . ` � : - <br /> ; ❑ If I sell my property, I wili make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular.basis. ' ' <br /> I � I am enclosing all of the necessary papenvoiK(use the yellow'Rebate Submitlal Checklisl). ' � <br /> Select trom the following: F <br /> 1 <br /> ❑ Tho conlraclor identified downspouts or olher drainage Ilines lhal were connecled to my se�der� <br /> line(behveen my house and the installed device)and removetl,or rerouted Ihem. I <br /> . . _ � <br /> � To my knowledge,my propeAy has no downspouts or other�drainage connected to my seWerline': <br /> (behveen my house and the installed device). • • � <br /> ❑ The�e are downspc�uts or olher drainage lines connected to my sewer line (between my house- • � <br /> and the'instelled device). I undersland that leaving Ihese conneclions creates'a'risk of Ilooding , <br /> and I accepl ihal risk. • + <br /> � <br /> f <br /> Slgnature Dafe � � � 2 �� 5 f,' <br /> i � <br /> ; � � <br /> i <br /> � <br /> �_ _ _ _ _ __ ___ __ _ ___ _ __ _ _ I <br />