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i � <br /> I <br /> �,�/� Backwater Prevention Device Rebate Program <br /> '��— Rebate Application Form <br /> I w��. .rc„ <br /> I �•� <br /> � -- -- -- - --- <br /> PropertyOwnerName: _._(�_,l.1FfoR-� �EfFRE`� aHRDY <br /> InstallationAddress: ��O�Z WE"fl'�URG AVG <br /> Cily: �VERE?T Stale:. W RSN___Zip: 98�� <br /> IMailing Address(i(di)ferenQ:�_y-32 WE RL__11��. <br /> � Ciry:_ :VCRETr State:�JASN Zip: 982c�1 <br /> Emaii: . Fhone: (475) 252-v��l <br /> Total C� � to Instatl Device (lrom con(racfor invoice):$�l�_��__ <br /> I Please verify the following: <br /> i � I am lhe.wner of the property where the backw�ler prevention device was inslalled. <br /> ' �T I worked with:he conlractor to delermine Ihe location(or the backwaler prevenlion device and <br /> � ;mderstand lhat the uecision regarding Ihe location oi lhe device was mine. <br /> i <br /> f f�� My coniractor instructed me how to access,inspect, and maintain the device. <br /> I �" I understand lhat I am responsi6le for maintaining the backwater prevention device and keeping <br /> I il in good�vorking order, unless il is installed in the city right-o(-way. <br /> i �' If I sell my properly, I will make potential buyers aware of t� er prevenGon device and � <br /> Ihe need lo inspect and maintain it on a regular basis. , <br /> I � I am enclosing all oi lhe necessary paperwoik(use the yei•. nittal Checklist). <br /> iSelect from the following: <br /> [x] The cantractor identified downspou�s or o�her drainage Ilines L ial were connected lo my sewer <br /> line(belween my house and lhe inslalled device)and removed,or rerouled than. <br /> �] To my knowledge, my property has no downspouls or other drainage connected to my sewer line + <br /> (belwcen my housc and lhe installed device). <br /> �� There are downspoWs or other drainaye lines connecled lo my sewer line (between my house � <br /> and Ihe installed device). I understand that leaving these conneclions creates a risk of tlooding <br /> � and I accept ihat risk. � <br /> � i <br /> � <br /> � <br /> Signafu�4���� Dafe�v/!,S <br /> � ��` <br /> I <br /> i <br />