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��Backwater Prevention Device Rebate Program <br />Q, Rebate Application Form <br />Property O�•mer Name: STcv e� � T��C�S � 1.1�n� I <br />InstallationAddress: ��y v��j�✓7LG�._-_�_i'tJG - , <br />City: C-�.��?�-�}d --- Slale: _�,11c? --- Z�P �1�2c� I _ � <br />Ivlailing Address (ildi/ferenl): <br />City' <br />State: _- -- Zip:. . — _ — - <br />Emaii. _ �ti'(SYYL��11�U1?S� ��.ia1.�s��v� Phone: (`i3:1 _31_'i -'��_`L_ <br />bU <br />iotal Cost to Instal:Device (lrorn contractor invoico). 5 LS00= __ <br />i -- - <br />Please verify tlie following: <br />.� I am lhe otivner of the prop�rty �vhere Uie backwaler prevention device was installed. <br />f�?' I�aorked �vith lhe contraclor to delermine lhe localion for Uie back� �ater prevention dewce and <br />understand that the decision regarding the location ot Ihe dewce teas mine. <br />[;� tvly conlraclor mslrucled me how ro access, inspect, and mainiain the device. <br />�f I understand that I am responsihle for maintaining the backwater prevention device and keepmy <br />d in good a�orking order, unless il is installed in Ihe city righ�-of-way. <br />�j If I sell my properry, I wlll make polential buyers avaarc of the backwater prevention device and <br />the need to inspect and maintain it on a reyular basis <br />� I am eni.losing all n( �he ner.es;nry F�:ip��rr.oik �use ih� �ello�v Rabate $uhmitlal CheCkhst) <br />Sclecl from Ihc following: <br />LJ �?he conlr�cloi idenldied du�t�n�,��outs or u:her diainage Ilines �h�d v:�_ro �unnecled to nry scc;ei <br />hnc (bel�veen my house and Ihe installed devic�) and removed, or rerouted Ihem. <br />� To my know:edge, my property has no downspouls or othcr drainar�c connecled to my sewer line <br />(hclween my house and lhc inslalled devir,e). <br />j � There arc downspouts or other drainage lines r.onnected to my sewer line (behveen my house <br />�nd ihe installed device). I undersland �hat leaving ihese conncclions creales a risk o( Ilooding <br />and I accep� lhat risk. <br />,� <br />� � _ -- <br />" � S <br />Signature�` �, >r,(�--Dafe _S/i 7 � <br />� <br />