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Backwater`Prevention Device Rebate Rrogram <br />: � . E� : � Rebate Application Form <br />Property Owner Name: S G� R EA y/ f�A � 1` A I W('�� I. LL <br />.. Installation'Address:�� �� b �) �% � T"� � �� � �1 � �A V G � � � � � <br />Ci�y: �L�P—ET� State: L.� f� . Zip: ���O �.. <br />Mailing Address (if diIlerenf): �0 �� � � L�y � v� <br />Ciry: G 1� C�G 1"� State: �/�/ � z�P: 9 g ao I <br />Email: �a V� W_r �'1 Gi1 C �� @ q�VI A. GO Phone: (ylS) 3 v�La 3 I� � b <br />y�. <br />?olal Cos� �o Install Device (/rom confractor invoiceJ: $ �( 5�0 <br />. Q lC �-0 �,., P ro�t, +� ('Jv her <br />Please verify the following: � <br />. ��.ro,,h�. UT 3y3]. `i�,M� ��u� <br />�� I am lhe owner o( the propeAy where 1h� backwater prever.tion device was installed. L��� <br />(r(�.: � <br />� 1 worked with the contractor to delermine Ihe location for the backwater prevention device and I,L/15I�� <br />understand thal the decision regarding the location of the device�was mine. <br />.j�' My contraclor instrucled me how to access, inspecl, and maintain the device. . <br />•� I understand thaPl am responsible for maintaining the backwater provention device and keeping <br />il in good working order, unless it is installed in Ihe city ngh4of•way. <br />�'� It I sell my propeRy, I will make potential buycrs aware of lhc backwater prevenlion device and <br />. the need lo inspecl and maintain it on a regular basis. <br />. ,���i�am enclosing all of-the.necessary penerwork (use the yellow Rebate�Submittal Checklist). . .� <br />Select from Shc following: <br />. . • [] ?6e.contraclor idenlified downspculs or other drainage Ilines thal were connecled to my sewer <br />,,:line (belween my house and the installed device) and removed, or rcrouted Ihem. <br />� To my knowledge, my propeKy has no down;pouls or other drainage connecled fomy sewer line <br />.�, (behveen my house and.lhe installed device). • <br />::� There are downspouts or o!her drainage lines connected to my ::ewer line (behveen my house <br />�� . and ihe �nstalletl�device). I�undarsland thal leaving lhese connections creates�a risk.of7looding . <br />� antl,I�acceptthatrisl<. � � � � � : � <br />Sfgnature��� Dafe�i�/ (-1 --. <br />, . . � �� <br />