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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> , Properry Owner Name: S�C-�"C" �'''"`0�"�� <br /> ��gmuauonnaareeg: 1�32 I,��n'^�'�n.� <br /> Cily: L'�.F�{l� Stete: 4�14 �;P. �it�-�-' 1 <br /> Malling Address(il dlNerenp: <br /> Cily:_ S4[9: Zip: � <br /> Ema�i: Stf►�i�nlr��'D¢a6a�g—utn.ca� anone:� ) `1S� zof v <br /> i <br /> Total Cosl to Inslall oevice(Irom conhactalnvofceJ:S <br /> Pl�eaa verHy tlN following: <br /> �1 am the owner of fhe property where the backwater prevenGon device was instelk0. <br /> �I worketl wllh Ihe eanNsdor to delertnine tM beatlon tor the baekweter preventlon doviee and <br /> underelend fhet tAe dedaion regarding Me localion of lhe devlce was mine. <br /> �My contnctof fn9lruded me how to'acccss,insped,and malntsin the deviee. <br /> � I undaroWnd Iha[1 am responsiCte for melnt6lninp Uie backweter provenlan Gevice end keeplrg <br /> it m good waking order,unless R Is inslelled In Ihe dly Aghtot•way. <br /> � tl t sell my pmperry, 1 will meke polenUei buye�s aware of Ihe backwater preventlon devloe and � <br /> the nead to inspect and maintein Il on a regular basi9. <br /> �t am endosing all of lhe necessary paperwork(use Me yellow Rebate Submlttel Chacklist). <br /> Ssled/rom tha lollowinp: <br /> J�The conUacror itlentllled downspouts or olher drainege IOnev thal were Conneded to my sewer <br /> �Ifni:(henveen my house and IAe insWlled deviw)and removed,or rerouted them. <br /> �To my knowtcdge,my property has no downspouLs or other drafnape connected to my sewer Ilne <br /> (Eehveen my house anA the insta!led deviae). <br /> �Them are downspouts ar other diuinage lines conneUed to my Sewar line(betwee�my house <br /> and Ne InstaOed devkeJ,I underslend lhal IeaWng these mnnectlons creales a rlsk of flootltng <br /> end 1 eetept thel Ask. <br /> Signature� -/�_ oaie /�/��i7 <br />