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f <br /> i <br /> � <br /> i <br /> f <br /> �� Backwater Prevention Device Rebate Program f <br /> �w�F,,, Rebate Appiication Form ! <br /> .�--- � <br /> � <br /> Property Owner Name: ail��iL <br /> Installation Address:�/�1 �{.IY110/`e <br /> City: �� State� fj/C!/ 7_ip:���D.� <br /> � <br /> Mailing Address(il dil/erenf): A/fj� � <br /> 1 <br /> City: Slate: Zip: ' <br /> i <br /> Email: Phone: ([/,�'_��g�-3��, <br /> Total Cost to Install Device(from contractor invoice): S 2O6I � 4� I <br /> I <br /> -- - --- — _ � <br /> � <br /> Pleasc verify the following: I <br /> �' I am the owner of the property where the backwater prevention device was installed. � <br /> i <br /> �I worked wilh lhe contraclor lo determine the location for lhe backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> �My contractor instructed me how to access, inspect, and maintain Ihe device. � <br /> [�'I understand thal I am re^ nsible(or mainlaining Ihe backwaler prevenlion device and keeping ! <br /> il in good working order �ss il is installed in the city right-of-way. � <br /> ��If I sell my propr.rty, I will make�x�tential huyers aware of the backwater prevention device and � <br /> the need to inspect and maintain if on a regular basis. I <br /> [''` I am enclrsing all of the necessary paperwork(use Ihe yellow Rebate Submittal Checklisq. � <br /> I <br /> Select trom the following: I <br /> ��The c;ontrar.tor identified downspouts or other drainage Ilines thal were connecled lo my sewer i <br /> line(betH�een my house�nd the inslalled device)and�emoved,oi rerouled thr.m. 1 <br /> To m knowledc c, rn � <br /> �' y � y prope�ty has no downspouls or olher diainage conncr.tr_d lo my sewer linr. , <br /> �(hetween my house and ihe in,talled device). � <br /> Lf There are downspouls or olher drainac�e lincs wnnected to my sewer tine(belwer.n my house ! <br /> and lhe instalted device). i understand ihat leaving ihese connections r.reates a risk of Oooding i <br /> and I accept lhal risk. �� <br /> � <br /> I <br /> I <br /> Signature�l���RnN/Y�t/ Datc .Z.-!'�r—. j <br /> i <br /> I <br /> � <br /> i <br /> I <br /> i <br />