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t <br /> i <br /> � <br /> � i <br /> i <br /> ; <br /> Backwater Prevenfion Device Rebate Program � <br /> �^%�„ Rebate Application Form ; <br /> i <br /> PropertyownerName: �� C?ADL1�.Q i <br /> installatlon Address: ��� /p��G�C�._,.C� � <br /> Ciry:�U�i�� Staie:��_7.Ip: `11S�LJ� <br /> Malling Addreaa(NdHfetenQ: � <br /> Cny: State: Zip: <br /> Email: /�It?��, ad/� �) �MrE��./'nht Phone:��� i <br /> —�, � <br /> Total Cos1 lo Instail Drvlce(hom conRadar fnwfoe):E��.'�9 I <br /> i <br /> • i <br /> Pkase verHy thc tollowlnp: i <br /> (� I am the Owner of the pmpefty wlrere the baehwale�preve�ribn devMs vres Instaned. ' <br /> [g I worked wilh Ne caM�edor to detem�une Ihe locatbn for Me bad�wai0x prwentton devtce and <br /> unde�amnd thet the declNon regarding Ihe bcation ut Ihe Gevke was mine. <br /> [�'My conirador insavGed mo how ro aooese,inspaci,and mairrdln tlte device. <br /> �' I urMeratancl that I am teaPone�le for maiMefn;�g the becAwater prevention devics end keeping . ; <br /> rt in good wotkitp order,uNess it ia irtslatled In the city righbol�wey i <br /> �If 1 sell rtry propeRy, I w01 make potertliai Duyers aware of ttte baekweter prevendon devfce and � <br /> tha neod to!nspeCl end maintaFn it on a reguler bo�is. <br /> � I am endosfng all oT tAe necessary Paperwak(use ihe yelbw Rebate SubmROal Checkl�st)• ! <br /> Sslact 1rvin fhe fo(IowMg: � <br /> ❑ The contrdqOt iOeMifred dwmspouts or other drafnegc Itinea thel weie conrtacted to my�ewer � <br /> Ilne(behveen my house end Ihe tnslalied dcvice)and rCmoved,or rerouted lhem. <br /> �'To my kmwle0pe,my property has no downspouts or olher tlrafnage oonnede0 to my eewer line , <br /> (befiveen rtry house arM 1he irtstalied device). <br /> ❑ There are downspouts or olher drainape Ilnes conr�eUeC to my sewer line(Delvrean my�ousa � <br /> and fhe Instalkd device).I understand ihat teaving these connedions ereates a risk oF flooding <br /> atra I aCCept Nst risk. I <br /> � I <br /> � <br /> / <br /> S/gnaNrn ��e '_��� � <br /> ; <br /> I <br /> � <br /> i <br />