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i <br /> ; <br /> Backwater Prevention Device Rebate Program i <br /> �1��y�" Rebate Application Form i <br /> � <br /> Property Owner Name: ��I VVvI �!V ���L� � _ � <br /> Installation Address: 1 �(} �0 VV Z��'1'I(�1/Y— /��'' ` <br /> City: ,Q State:�_Zip: �! j <br /> Mailing Address (ildiNerentJ: i <br /> City: Stato; Zip: i <br /> Email:�G�I�Y /A,1/1 C� l(A'�I�U�j.I', ��Phone: ��;l 3�iU �� � � <br /> Total Cost to Install Device (from contractor invoice):$__ [�) ��j(;C�,� ; <br /> � <br /> i <br /> Please verify the(ollowing: � <br /> � <br /> �tam Ihe owner of the proparty where the backwaler prevention device was installed. � <br /> I worked with the conlractor to determine the localion for ihe backwater prevention device and <br /> undersland that Ihe decision regarding lhe location o(the device was mine. ( <br /> f�My contraclor inslructed me how lo access, inspect, and maintain Ihe device. ; <br /> nderstand that i am responsible for mainlaining the backwater prevention device and keeping � <br /> it in good working order, untess it is installed in the city right•of-way. i <br /> i <br /> �I sell my property, I v✓II make potential buyers aware ot the backwaler prevention device and i <br /> the need to inspect and maintain it on a regular basis. � <br /> �I am enclosing all of Ihe necessary papenvork (use the yellow Rebate Submitlal Checklist). ' <br /> I <br /> Select from tht !cllowing: � <br /> i <br /> �he contractor identified downspouls or other drainage Ilines ihat were connected to my sewer � <br /> line (betwaen my house and the inslalled device)and removed, or rerouted them. j <br /> �To my knowledge, my properiy has no downspouls or olher drainage connacted to my sewer line � <br /> (belween my house and the installed device). � <br /> i <br /> l <br /> �] There are downspouts or other drainage Iines connecled to my sewer line(belween my house ; <br /> and the installed device). I understand Ihat leavmg Ihese connections creales a risk of Oooding � <br /> and I accepl that risk. i <br /> : <br /> � <br /> Signature Date � <br /> � <br />' i <br />� j <br /> I <br /> � <br /> I <br />