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-�`` --- — -- - -- -- — - -- -- - <br />Backwater Prevention Device Rebate Program <br />Rebata Application Form � <br />Prouerty Owner Name• SG�1 CGl/�el� ���YIO� �/Gi� <br />Installalion Address: Z�J�`'i I�i Y9 �✓1 ��I, �Ve <br />v <br />City: ��/eVet't Stale: �✓/i7 <br />Mailing Address (il di(lerenQ: <br />City: <br />Email: <br />State: <br />Total Cost to Install Device (�rom contrac�or invoice): $ <br />Please verify ltie following: <br />GBzo! <br />Zip: <br />Phone:( <br />� am the owner of Ihe property whe:e lhe backwater prevenlion device was installed. <br />j�I worked wilh the contractor lo delermine the localion for the ba„kw�ter prevenlion device and <br />understand that lhe der.ision regarding lhe �ocation of the device was mine. <br />(�A4y contraclor inslructed me how �o access, inspect, ��d mainlain the device. <br />(�I undersland thal I am responsible for maintaininy the backwaler prevention device and keeping <br />�t in goad �+urki>>g order, unless it is inslalled in the city righ4o(-way. <br />f I sell my property, I will make pntential huyers aware of lhe 6ackvrater prevention device and <br />Uie need to inspecl : nd mainlain it on a regular basis. <br />�U I am enclosiny all ol the necessary p;ipenaork (use Ihe yello�v Rebale Submitlal Checklist). <br />Select from lhe following: <br />jyj/The conlraclor identified dov+nspouls or olher drainage Ilines that we« a connecled to my se�ver <br />line (betwccn my house and the inslalled device) and removed, or rerouled them. <br />�To my kno�ti�ledge, my properly has no downspouls or other dramage connecled lo my sewer line <br />(between my house and the inslalled device). <br />� � There arc downspouts or other drainagc tines conneded to rrry sewer iine (between my hause <br />and ihe installed device) I undersland Ihat leaving these connecGons creates a nsk oi (loodiny <br />and I ac^.ept thal risk. <br />Signatu��� ���'�-- Da(e —r �����'S <br />