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; <br /> � I, <br /> � <br /> i <br /> Backwater Prevention Device Rebate Program ; <br /> �� Rebate Application Form i <br /> � <br /> � <br /> i <br /> Property Owner Name: �r�� �rn �o �� � <br /> i <br /> � <br /> Installation Address: ��9 ��-�`� �"�'`=- I <br /> �✓EJ?-ETT state� w�4 zip: 9�Z°/ ; <br /> ciry: � <br /> 1 <br /> Mailing Address(if diNerent): ' <br /> i <br /> City: State: Zip: <br /> Email: — — <br /> Phone: ( ) ? <br /> � <br /> Tolel Cost to Install Device (�rom contrectorinvolct;: 8 a`�3� g b �� <br /> � <br /> � <br /> i <br /> Pleaso ve�ify lhe following: � <br /> f <br /> � I am the owner of the propeAy where lhe backv+ater prevention device was�r.stalled. E <br /> �� I worked with Ihe contractor to determine the location for the bacfcwater prevention device and ; <br /> understand Ihat the decision regarding the locafion ot the device was mine. � <br /> �My ConUactor(nstructed me how to access, inspecl,and maintnin Ihe davice. '` <br /> I understand ihal I am responsible for maintaining lhe backwaler prevention device and keepfng { <br /> � il In good working order, unless it is installed in the city nghl-ot-way. � <br /> � If I sell my property, I will make potential buyers aware of the backwaler prevention devlce and ; <br /> the need to inspect and maintain it on a regular basis. � <br /> � I am enclosing all of the necessary paperwork(use the yellow Rebate Submitlal Checklisl). '. <br /> Selecl irom the following: ; <br /> ❑ The contraclor identified do�vnspouts or other drainage Ilines that were connected to my sewer j <br /> line(between my house and the inslalled device) and removed, or rerouted them. <br /> r,�To my knowledge, my property has no downspouls or olher drainage connecled to my sewer line , <br /> ( (between my house and lhe inslailed devlce). <br /> � There are dovmspouts or other drainage lines connecled lo my sewer line (between my house <br /> and the inslalled device). I understand that leaving these conneclions creates a risk of flooding <br /> and 1 accept thal risk. <br /> Signafure � / Date 1� � l���� <br />