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-- --�--�, _ <br />Backwater Prevention Device Rebate Program <br />Rebate Appiication Form <br />Property Owner Name: <br />Inslallation Address: <br />. . <br />(laln I C <br />I �f�,( p <br />City: ��f�r State: _ YV_t�—_ Z�P � b�— <br />Mailing Address (il dillerenf): 2S�� �Ii �f� I� IG Y�1( � <br />r �JA—� --- <br />City: G`f���� Stale: V� �} Zip:__� �i�'D <br />{� 1 �---- <br />Email: UC'tto�2�0 �O+WOD� CO'�^'� Phon� ��� �7r�.3��D _ <br />Total Cost to Install Device (frorn contracforinvoic 1: $ �-S6aQ4, <br />Please verify the following• <br />j� am the owner of Ihe property where the backwater prevention device was installed. <br />� worked wi;h the contr�clor to delermine the localion for the backvaaler pievenlion device and <br />undersland thal Rie decision regarding Ihe localion of lhe device was mine. <br />�� My contrador inslrucled me how lo access, inspect, and maintain the device. <br />� I undersland lhal I am respunsible for rnainlaininy the backwatu prevention device and keeping <br />it in good working order, unless il is inslalled in the city rir�h!-of-�vay. <br />[�If I sell my property, I will make potenlial buyers aware of lhe backwaler prevenlion device and <br />the necd lo mspect and maiidain i� on a reyulaar basis. <br />�I am r.ndosing all o( Ihe necessary papervvork (usr, the yell�w Rebate Submiltal Checklist). <br />Sclect (rom ttic following: <br />�he contractor idenli(ied dov�nspnuls nr olher drairmge 16nes Ihal were connected to my sewei <br />�lii e(befwcen my house and ihe insL•�Iled device) and removed, or rcrauled them. <br />o my knowledc�r, my properly has no downspouts or nther drainage connected lo my sewer line <br />(belwer.n my house and ihe inslalled device). <br />[J There are downspouls or alher drainage lines connected lo my se•.ver. line (between my house <br />and the installed devi�e). I understand Ihal leaviny Ihese conneclions creales a risk of 1louding <br />and I accr.pt lhat risk <br />Si na(ure � <br />g � ��% Da(c�%D�1��_ <br />� �l --- <br />