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I <br /> I <br /> � <br /> ; <br /> �� Backwater Prevention Device Rebate Program ' <br /> �\��,.,. Rebate Application Form � <br /> �..�.. � <br /> --__--".� . .__ __ ---- --------�-- _ . .. ----___-- � <br /> Property O�vner Name:�JJl� G' �Il%�(r___ _____ �f <br /> Installation Address: _����� rZ���-��~ _ __ ' <br /> '✓vr�.�!� State. �'� Zi "� � i <br /> a�y: � P: 9g'�_ _ � <br /> A4ailuig Address (i7dilferenQ: --_----- _- 1 <br /> � <br /> Cily: --_--- Slate _Zip: � <br /> Email' --__- ----_ — Phone: ( ) � <br /> r � <br /> Total Cost to Inslail Devicc(lrom con7rar.(or invoir,e) $�''�7J��� __ <br /> � - <br /> --- -- -- — -- - _ _ __.. ._. t <br /> ! <br /> Please verify the tollowing: � <br /> ! <br /> �I am the owner of the property whr.re Ihe backwaler prevenlion device was insl,died � <br /> [( I worked viith lhe conlraclor to determine�he localion (or Ihe bac cwater prevention device and � <br /> undersland Uial lhe decision regarding Ihe toca(ion of Ihe devia was mine. <br /> �� My coNrar.tor instrucled me hav lo access, inspect, and m�intam Ihe device � <br /> ��I understand lhal I am responsihlr. lor mairdaining Ihe backwaler prevr.ntion device and kecping i <br /> il in good woikiny order, unless il is inslalled in Ihe cily riyhl-of•way } <br /> [��If I sell rny property, I wlll make polential biryers aware of Uie backwaler prev�n(ion device and i <br /> lhc need lo inspect and rnaintain it on a r�yul;�r basis. � <br /> ��'I arn endosing all o(Ihe necessary paperv+ork (use �hc yellow Rebale Subnidted Chr.cklist) ( <br /> � <br /> i <br /> Select from the following• � <br /> ❑ The conlractor identified downspouts or olhr,r drainaye Ilines Ihal were r.onnecled lo nry sr.wr.r � <br /> line (belween nry house ;ind the inst:dled dr.vir,c)and rernovcd. or rcroulr.d Ihent � <br /> i <br /> I�lo my knowledge, my pwpcity h,�s no do�vnspouls or other drama,rye connecled tn my sewcr linc � <br /> (belween my house and Ihe ins(alled device). � <br /> � <br /> � J There are downspouts ar olher dwinagr lines cvnneGed ln my srwer line (6r.hvecn my housr, � <br /> and Ihc installed device). 1 undeisland Ihal leaving Ihese r.onneclions creaies a risk ol IlOoding � <br /> and I ar,cepl Iha� riSk. � <br /> � <br /> .� 1 � <br /> '!/ �� / <br /> � Ti �� J( -''- / � <br /> , , / <br /> Slqn�tllnc _I_ . . . -��-•-�... (�---Datc—C_Q�/_�I /.�� � <br /> _ __ .._ ___ . � . ._ - <br /> i <br />