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_ _—.---- -- --� <br /> � Backwater Prevention Device Rebate Program <br /> E„ Rebate Application Form <br /> �Property Ovmer Name: L�a v . •� ��� �'_ f� <br /> Inslallation Address: 2 S � �i , �.U��f 1 �' U �' <br /> City: �_i, r c-T� _ Stale: _���__Zip: I � � 2- � --� <br /> Mailing Address (i/di/7erenf): <br /> City: State' Zip: <br /> Email: Phone: (�g") 2,`I ��— 72� � <br /> Total Cost to Inslall Device (Irnm contractor invoice): 5_ ���_�0 _ <br /> I_ <br /> F'lease verity the following: <br /> [7 I am Ihe owner of lhe property where ihe backwater prevention device�vas installed. <br /> [� I �.vorked with the conlractor ro determine the location for lhc backwaler prevention device and <br /> understand that the decision regarding the Iocation of the device was mine. <br /> (�' h1y conlractor mslructed me how to access, inspect, and maintain the Aevice. <br /> [� I undersland lhal I am responsible for mainlaimng lhe backwater prevention device and keeping <br /> it in good working order, unless it is inslalled in the cily right•oi-way. <br /> (j�'-It I sell my property, i will make polential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> (�]' I am enciosing all of lhe necessary papenvork (use Ihe yellow Rebate Submittal Checkiist). <br /> Select from the following: <br /> [] The contraclor identified downspouts or other drainage Ilines that were r.onnecled to my sewer <br /> line (hetween my house and Ihe installed device) and removed, or rerouled ihem. <br /> �j,�" To my knowledge, my property has no downspouts or olher draina�e connected to my sewer line <br /> (behveen my house and the installed device). <br /> ❑ There are downspouls or olher drainage lines connected to my sewer line (between rny house <br /> and Ihe installed device). I undersland Ihal leaving these conneclions creates a risk ol lloodng <br /> and I accepl lhat risk. <br /> � � <br /> Signature Date� <br /> l <br />