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i <br /> ; <br /> � <br /> i <br /> �^� Backwater Prevention Device Rebate Program ; <br /> �, Rebate Application Form ' <br /> -- --- - i <br /> Property Ovrner Name: ��i�:f �� L %/✓!�• i <br /> � <br /> iInstallalion Address�I I � :i {�y i /��(. , �f- i <br /> Cil � C�G•�jtC� � r '�l_`JJ��� � � i. � ( <br /> iy. l / —"' olale ._ . . __ _ Z�p /. .' !_.� , _ i <br /> Mailing Address (if di(/crrnl) � <br /> ICil}': _ . Stalc .__ _ .... . . . Z p. . . . ---- j <br /> i -- � - - - - --�-- . . . ._ . ._. . <br /> I � <br /> Email Phonc ( )_ � <br /> iTotal Cosl lo �nstall pevia� (Irom conlrac(orinvoice) 3 _�l_!E __ _ -- _ ' -- � <br /> �--- - -------- - - _.I � <br /> I <br /> Plcasc vcrity the fol�owing: <br /> ��I am the owner of Rie propeiry where Ihe backwa(e� prevenl�on device was in;LNled. <br /> �;,} I worked�vilh Ihe contractor lo defernune the location for Ihe backwalrr preventinn dr,vicr. and � <br /> understand fhal lhe decision regardinq Ihe Iocahon o� Ihe device was mme � <br /> [l My contraGor insVucted me hov+to access, inspect, and mainl.un Ihe device � <br /> � .� I unde.sland Ih;al I am respons�hle lor mainl[nn�ng the backwalr.i , ,�vcntion dev�rn,m;l kecping � <br /> R in yood�ti•orkiny otder. un�ess�I is ui:;lalled m Ih^cily right-of-way. . t <br /> �y�lt I sell my property, I will rnakc polr.nlial buyers a�vare ot Ihe backwatr.r preven�inn device and � <br /> tlie need lo inspect and mainlain i( on a regular hasis. j <br /> �� I ;�n�i enclosing all a(Ihe��eCeSsary pripen•iork(use Rie yel�qw Rebn(c tiulnni�lal Checklis�) <br /> Scicct from the(ollowing: ! <br /> t <br /> [� The r.ontraclur identdied davnsp�nts ni olher dcunaqe Ilu�e�; Ih;il wr.rr. r.onn�a:lr.d lu my Sewer ; <br /> line (betwr.cn my hou:;c and Ihe insl;iAcd device) and reinoved, oi reruulcd Iheni � <br /> ` <br /> �'�� -fo rny knowledge. my proper�y h�s no do�vnspouls or ofhei di;unayr. connedr.d lu nry scwer Lne I <br /> (bchver.n my huuse and Ihe ins�,�llcd device) i <br /> � <br /> i <br /> � �j 1 her�a,nt dnv.aispouls or ulher drainagc lines r.onnecicd to my srsvni luu• (hclm�ecn my huusc • <br /> and Ihe �.nsI,�IIeA d^vir.e) I underst�nd Ihal Ir,��v�nr� Ihe;e cunnuclions uc:dnn ;i m:k ul Iluodinq � <br /> nnd I ;ir.�.r,�N tho� ns4 i <br /> I <br /> / �� i <br /> Siyn:iluic�l_�--tiG- ' � _ �� _ Dalc C' - `.+ . � `� . - . <br /> i <br /> 1 <br /> t <br /> � <br />