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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Prope�ty Owner Name: M�G!��� � �Z1 qE'r/�^�'i <br /> J <br /> Installation Address: o?/o��-J /�C/cCr /� dP . <br /> city:��/��'e� State: Gu/-�- zip: 9 �u / <br /> Maiiing Address (ildilferenf): 937pi vr+�h ���2 LUd�/ <br /> i <br /> City: f30�h/�/ state: G�Jf� Zip: 9�� � <br /> EmaiC � fr/i/�9 � �-o �, (a�"' Phone: (/�/aS 3� 3—Sy 7 <br /> Total Cost to Install Dev�e (from contractorinvoice): 5�"/> �• �� <br /> Please veri'ry lhe following: <br /> �-I am the owner ot lhe preoerty where the backwater prevention device�•,as installed. <br /> �'l worked with the contractor to determine the localion for the backwater prevention device and <br /> undersland�hat ihe decision regarding the localion o(the device was mine <br /> �p�1y contractor instructed me ho�v lo access, inspecl, and maintain lhe device. <br /> � understand lhal 1 am responsible for maintaining the backwater prevenlion device and keeping <br /> d in good�vorking order, uniess it is inslalled ir Ihe city righl-of-way. <br /> (�_If I seU my property, I�vili make potenlial buyers aware of the backwater prevention devicc and <br /> the need to inspect anA maintain it on a regular basis. <br /> �,I am enclosing all of lhe necessary papenvor4(use the yellow Rebate Submiltal Checklist). <br /> Select(rom tl�e following: <br /> [] The conUaclor identified downspouts or olher drainage Ilines thal were connected to my sewer <br /> line (betwcen my house and lhe installed device)and rem�,ved, or reroulzd them. <br /> �(] To my kno�vledge, my pwperty has no do�vnspouls or olher drainage connecled to my sewer line <br /> (between my house and the inslalled device). <br /> ❑ There are do�vnspouts or olher drainage lines connecled to my sewer line(be�veen my house <br /> and the installed device). I understand ihat leaving lhese conneclions creates a risk of flooding <br /> and Paccept that risk. <br /> / <br /> S%�Rature , �/ Dafe �/� //� <br /> � <br /> - - - _ _ _ . . - --��_ _ . - - - - - — -- -� <br />