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! <br /> I <br /> ; <br /> I <br /> � Backwater Prevention Device Rebate Program � <br /> Rebate Application Form , <br /> � <br /> Property 0wner Name: C/IJC ��/1 �r••[o� <br /> Installation Address � �� c��l�O(�� �V cC � <br /> City: ���2�� State: l�� � Zip: ,nj�'z0 � � <br /> I <br /> Mailing Address(i/dil(eionQ: � <br /> Cily: Slate: Zip: ' <br /> i <br /> Email: Phone (� 2-32- 9��� � <br /> Total Cost to I�stall Device(from contractorinvoico): 3 �-.� !� r V � <br /> Plcase verify the following: <br /> I am the owner of the property where the backwater prevention device was installed. <br /> Q I vdorked with the contraclor to determine lhe location for the backwater prevention device and <br /> undersfand that the decision regarding the location of the device was mine. ' <br /> �y contractor inslructed me how to access,inspecl, and maintain the device. , <br /> �-1 undersland that I am responsibte tor maintaining the backwa�er prevention device and keeping � <br /> it in good working orAer, unless it is installed in the city right-o6way. � <br /> [,�((I sell my property, I will make potential buyers aware of lhe backwater prevention device and � <br /> Ihe need to inspecl and rnaintain il on a repular basis. � <br /> � I am enclosing all ol the necessary paperwark(use the yellow Rebale Submittal Checkiist). ' <br /> Select from the following: <br /> �'"lhe contraclor identified dovmspouts or other drainag�Ilinr.s Ihat were connecled to my sewer <br /> line(betv✓een my house and lhe installed device)and removed, or rerouted ihem. <br /> .�To iny krawlr.ifoe, my property has no downspaufs or olher drainage connecled to my seveer line ! <br /> (between my house and lhe installed device). <br /> �There are downspouls or olher drainage lines connected lo my sev+er line(belween my house <br /> and the installed device). I understand that leaving these connections creates a risk oF floodinc� <br /> and I accept thal risk. <br /> i <br /> � p � ' <br /> L � <br /> Signafure � 'V Date l��1'� � <br /> t��� � <br /> , <br />