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i <br /> ; <br /> � Backwater Prevention Device Rebate Program � <br /> Rebate Application Form ' <br /> �.�,.. <br /> i <br /> Propeity O�vner Name:_Pf9�L ���� '�—��''��� ! <br /> InslallationAddress: 3�/ � V�GlO L ' <br /> ' c�iy � .•,���i State� I�✓A z��: q�201 <br /> IMalling Address(il dilferent): �Z�3 �/�yl A1� � <br /> City: ��'���� Stale: _ �-+�f7 'Lip: 9��?�� <br /> EmaiL• !u/uP /�+ph+l0/,/t4 , G0lh Phone� (�/-Zi) 36i .713S" <br /> 7olal Cost to Inslall Uevice(from contreclorinvolce):S ' <br /> Plense verify tho following: <br /> �e/�I am thc oancr of the property where ihe backwaler prevenlion devir.e vras Inslalled. <br /> [�i worked with the contrticlnr lo dete�rninr.Ihe location lor the b�ckw2ler preventlon device and <br /> undersland Ihat Ihe declslon reyerding the locafion of Ihe device was mine. <br /> [J� My coMraclor inst«icted me how to occess,insper,t,anA maintain the device, <br /> [v�l understand Ihal I am responsiblc lor maintaining the backwater pmvention devir.e and kceping � <br /> il in good�vorking order,unless il is instnVed in the cily right-of-woy. i <br /> ��U I sell my property, I will make patenl�a�buyers aware of the backwater prevention device and � <br /> �c.need to inspeG and malntaln il on n regular basis. � <br /> im r.nr.losin�al10l ilir.nr,r.r.ssary paperwork(use Ihe yellow Rebale SWmlllel Checklist). � <br /> Sclecl from lhc tollowin�: �� <br /> n 'I he conlrader Itlonti(ied downspoins or oth^r dramage Ilines Ih�t were connected to my sewer I <br /> linc(helween my Iwuso rind Ihe Installed tlevice)and removed, or rerouled them. ; <br /> (v] 'Io my�cnowledge, my pio�::rty has no dovmspouls or olher drainane connectod to my sewer ilne <br /> (belwecn my housc and Ihe Inslalled devlce) <br /> � ] 7here are dovmspnuls nr nthcr drainagn Ilnes conneGed lo my scwer linr.(br.lwcr.n my houtie � <br /> and Ihe installed devicr.). I unAerstand ihat lenvhig�hese connedions creales a risk uf fiooding <br /> and 1 acr.ept Ihal nsk . <br /> �, <br /> Sfgnafu� �--__ -- �atc_ Z� �S I <br /> —� <br /> � <br /> � <br />