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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Properly Owner Name 7 rYi' (T/¢!r'�-C��51�- - _ _ <br /> Installation Address: �7_. .._�G��f1��C-----.- --- - <br /> __ <br /> — . ` _ <br /> Cily: C.�Ju�2��'/ �-- _ . Slal�>: _------ —Lip __.__ <br /> Mailing�ddress (il dilfmt�nQ: <br /> Cily:---- 31�dr. _ _—Zip_-- <br /> Email: -- - ---- _ - _—._ .. . --Phone: ( ) ------ --- <br /> r <br /> Tolal Cosl lo Inslall Devir,e (Irz>m r.nnlrnr.lur invoir.e): $_ 1 DD i <br /> J -- _ ._.. ._ _ . _.. <br /> Plcase vcri(y thc tollowing: <br /> �'�am�he owner of�he property�vhere Ihe backwaler prr.v�nlion device wm;inslalled <br /> � I worked with Ihe conVactor lo detennine Ihe Iocaiion for the bnr.kwalei picvenhon drvir.e and <br /> undersland Iha! lhe decision regarding Ihe lor.alion of lhe device was rninr,. <br /> [� My contractor instruded mc how lo ar,cess, inspec�, and mainL�in Ihr. dr.wr.r <br /> � I iuiderstand Lhal I �m responsiblc for mainL�infn� the bar,kweler picvenlian dev�r.n .md kui�piny <br /> il in good tvorking order, unless il is installed in Ihe city right-of-way. <br /> ���II I sr,ll my property, I will makc polcntial buyers nwarr.of Ihe b�ck�v;der prcvr.nliun dcvice;md <br /> Ihe ner.d to inspecl and nwinlain il on .i ret�ular basis <br /> r.�" I am cnclosin,a all o(Ihe ner.e:.s�iry p�perwork (use thr ycllow Rel�alr. SubindLil Chr�:klisl) <br /> Sclect from the Iollowing: <br /> ❑ The cunlraclor idenlihed dusvnspouL•;ui ulher diainage Ilinet: Ihnl werr. cunnr.r.led in�ny �;ewr.r <br /> linc (bciwecn my housu ;md Ihc in;ialled devir.r.)and rr.mmcd, ar ir.rouled tlicm <br /> ��� lo my knnwledJ�', mY Properly h:is no Aownspauls or olfier drafn,�g�a cnnneclr,d lu ury sewc� I�ne <br /> (bclwer.n my hou,e and Ihe insl;dlr.d dr.vir.r.) <br /> . (vfThere aic duwnspou�s or qlhr.r driina��u hnr.s conneded In my sewr.i hnr.(hr.lwr��n nry Luusc <br /> ;�nd Ihe incl�dled devic4). I undr.r.:l,tnd fh,il Ir.iving Ihe:;e canner.liuns r.iu.dr.s n u�.k nl Ilnuding <br /> and I ac.�:cpl lhal iisk. <br /> �� r� A�i�/ /__ / <br /> Srgnafurc Dafr. V � �5 <br /> � ` �_ <br />