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i <br /> � <br /> t <br /> 1 <br /> �I <br /> � <br /> �,��' Backwater Prevention Device Rebate Program i <br /> �w�� Rebate Application Form � <br /> ,��„ I <br /> I <br /> _-- � ,�. �- Jvj�� SUl,1� tl�l� � <br /> Property Owner Name: � <br /> ,(}� p�y/.'yI�. .�� '— � <br /> Installation Address: _�� � I���"--==1/t I_ � � <br /> Jq- � F�Suf <br /> Cily:��A -�' State �' ` Z�P , <br /> i <br /> AAailing Address(i/diNerenlJ: <br /> City: State: Z�P `; <br /> I <br /> Phone: ( ) <br /> Email: <br /> I� i <br /> Total Cost lo Inslail Device (Irom contracror invoicc): 5�5���{Y <br /> I <br /> Please verify the foilowin9: <br /> �'�I am lhe owner of the property where the backwaler prevontlon devi:a was installed. <br /> unders a d hat Ihe dec siontregarAingnthehlocal o,n of lhe1d^bce was m ne Vention device and <br /> [/rhly conlractor instructed me how to access, inspect,and mainlain tha device. <br /> ,[�I unAersland thal I am re.sponsible for maintaining the backwaler prevenlion device and keeping <br /> it in good working order, unless it is inslalled in Ilie city righl•of-way. <br /> �It I sell my property,I will make potenlial buyers aware ot the back�valer provention device and <br /> the need to inspecl and maintain it on a reguiar basis. <br /> �am enciosing all o�Ihe necessary paperwork(use the ycllow Rebale Submittal Checklisl). <br /> Selecl trom the following: <br /> � The conlraclor idenlified downspouts or olher drainage Ilines thal wero connected to my sewer <br /> line(behveen my house and the inslalled devicc)and removed,or rerouled lhem. <br /> �To my knowledye, my property has no downspouls or other drainagu connecled to my sewer line <br /> (belwer.n my house and 1he inslalled device�. <br /> � There are downspouts or other drainage lines connected to my se�ver linr. (bclwer.n my housc <br /> and Iho installed device). I understand that leaving Ihese connections creates a risk ol tloodmg <br /> and I acr.ept that risk. <br /> . <br /> \ � - ' ''" Dafe ' � � <br /> Signafure <br />