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i <br /> � <br /> Backwa.ter Prevention Device Rebate Program ' <br /> � Rebate Application Form � <br /> : <br /> --_ - --- ----- - --- � <br /> . , <br /> Property O�vner Name:��L(___�.__�\_l`';�' ( L( �'�\Q 1��1�' � <br /> - • \ -�-- , <br /> Installation Address:�_1�j�_l.�(''E VYIL��� _ . _ ___ � � <br /> City:_����:l�—_State:W G� Zip: � b (J�-�-,---- ' <br /> , <br /> Mailing Address(i(diHerent):__ ____ .__ _ __.___ ____ � <br /> i <br /> City:._ ------------ - State: ------ - Z�P'---- -- <br /> � <br /> Email: -- _ _ --- -Phone: (�5�-�)�Z.�iO;) ti/ � <br /> pp - -" <br /> Total Cost to Install Device(fran contracfor invaice): $_�����Q a___._.__ ` <br /> I <br /> { <br /> — � <br /> Please verify the following: I <br /> [�,] I am the o�vner oF lhe properly where lhe backwater prevenlion device was installed. <br /> � 1 worked with lhe conhactor lo delermine the location for tho backwaler prevention device and � <br /> understand that the doci,ion regarding Ihe location ot lhe de�ice was mine. <br /> i <br /> �, My conhaclor instructed mo how lo access,insped,and maintain the device. � <br /> [� I understand that I am responsible for malntaininy the backwater prevention device and keepint� <br /> it in good working order, unless il is installed in the ciry righl-of-way. <br /> �1 If I sell my property,I will make potenlial buyers aware o(the back�vafer prevenlion device and ; <br /> the need to inspect and maintaln il on a reaular basis, <br /> [,� I am enclosing all o(lhe necessary paperv��ork(use the yeilow Rebale Submiltal Checklisl). i <br /> Selact from the following: � <br /> � The conVactor identified dotmspouts or o�hr.r drainage Ilinns ihat were connecled to my st+wer � <br /> line(betwcen my house and the Installed devlcc) and removed, or mrouled Ihem. <br /> I� To my knowledge, my propeAy has�o dovmspouls or olher drainage connected lo my sower lint� <br /> 1 (belween my house and the inslalled device). ' <br /> ❑ Thero are Aownspouls or olher draina�e lines connected lo my sewer line (between my house ' <br /> and Ihe insleVed dovice). I understand that leavinc�Ihese connecfions creates a risk of tlooding <br /> and I accept that risk. ' <br /> � <br /> /1 ,� ' <br /> Signature_`-L��4"i-�.�1,_L���i,-4.�L4;�^_ Dafe—=Z--`��;�-1�- ' <br /> i <br /> i <br /> i <br /> i <br /> I <br />