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/��acKw+a�er Ptevention Device Rebate Program <br /> �� Ftebafe Rpplica4ion Form <br /> E <br /> Property Ownor Name: JO�,L'_C'���<Ll� . <br /> Installalian Address•__I g0� W�C`'YIUI� _tl.11e' _ <br /> Ciry;_��G+_-�— .Slate: W 1'T Zip:9 p� � <br /> Mailing Address(if dlflerentl: ___: — <br /> City•_ State: ---Zlp' _ <br /> Email:SeT l K�_50g � G{Z(u i � - CO:N Phone. �li) `7US=,36Zs <br /> J <br /> Tolal Cost to Inslall Device(fiom contracforinvoice): $?�3 �• � <br /> Please verify the following: <br /> G I am Ihe�owner of Ihe property where the backwater prevention device was inslailad. <br /> [vj I �voike�tivilh the contractor to detennihe thrlocation for the Dackwater prevendon deblce and <br /> understand thallhe decisian regerding the localion of�he device was mioe. <br /> [vj" My conlraclor instructetl me how to access,inspe�l,and mamtain the device. <br /> [�f I undarstand lhat� em responsible for meintairnng the backwater prevention device and Y.eeping <br /> it in good working order, unless Il is installed in Ihe city r�qhbof-way. <br /> [] If I eei: my property, I wlll make potenlial huyers a��are o(the beckwaler prevention device and <br /> �e need lo inspect and maiMairoit on a r2gular Aasis. <br /> [� I am�enclosing all of tho necessary peperwork(use t�e yeilow Robate Submittat�hecklist). <br /> Select fram the foilowing: <br /> L✓ Thu contiactor idenitfiod downspouls or other drainage Ifines thet were connected to my sewer <br /> Iine(huiwean my huuse anJ llro ins4'+tled d�vice)and removed,or rerouled Ihem. <br /> ❑ To my knowletlge,my propurty has no downspouts or olher tlrainy�c e connected to my sewer line <br /> (belween my house and the Installed�device). , , <br /> ❑ There are downspouts or other drainage lines cannecled to my sewer IinB(between my house <br /> �+nd the insl�lle.d device). I understand thel leaving ihose connections creales e nsk.o(floodmg <br /> and I accepl Ihal risk. ' <br /> � <br /> i -y/- / ^ <br /> I $1(flldhlf9�=U_/=��r y'�I—L�L`�'�f9��� ✓� O/v <br /> � � V <br /> � <br /> I <br /> I <br /> I <br /> �.—__— .�� —_—'___ __ _—'.___._'.—._ _'_'_' '_—__�_-_" • . <br />