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f � <br /> �,�}� Backwater Prevention Device Rebate Program <br /> � �„1�,:/�1�;, Rebate Application Form <br /> i �.� <br /> � <br /> Property Owner Name: Cr meNDO`�'X_ K �0 NN�0 N <br /> � Installation Address: I917 W/ET I"�(71Z �/�_V E. . _____ <br /> l <br /> c�ry:��F 7'7�' State: }�y�, Zip: �I�,20 f - 22 `F3 <br /> � Mailing Address(rl different): ----�—,��/��— — - <br /> i <br /> � City: State: Zip: <br /> ; Email: � Phone: (y25J 2$2 -� q.S�b <br /> I <br /> ; Total Cost to Install Device ((rom contractorinvoice): 5 <br /> I <br /> � - - <br /> ! Please verify the following: <br /> j � I am the owner of lhe property where Ihe backwater prevention device was installed. <br /> t <br /> I [✓f I worked�Nilh the contractor to delermine ihe location for the backwater preventlon device and <br /> � understand that Ihe decision regarding the location of the dovi: was mine. <br /> ❑ My conlraclor inslructed me how lo access, inspect, and rnaintain the dovice. <br /> ,_.. . . ..,�h <br /> If t��l understand lhat I am responsible for maintaining the backwater prevention dovice and keeping <br /> � it in good working order, unless it is installed in the city right-of-way. <br /> [✓f If I sell my property, I will make potential buyers aware of Ihe backwater prevention device and <br /> I the need to i�specl and mainlain it on a regular basis. <br /> I [V� I am enclosinr� all of the necessary paperwork(use the yellow Rebale Submitlai Checklist). <br /> Select from the follawing: <br /> ❑ The coniraclor identified downspouts or other drainage Ilines that were connecled to my sewer <br /> Ilne(belween my house and lhe installed device)and removed,or rerouted ihem. <br /> V�To my knowled�e, my property has no downspouls or other drainac�e connected tu my sewer line <br /> (hetween my house and ihe inslalled device). <br /> ❑ There are downspouts or other drainage lines connected lo my sewer line(between my house <br /> and the installed device). I imdersland Ihat leaving these connections creales a risk of flooding <br /> and I accept that risk. <br /> Signature P�r+. � �b'/�T�-��� Datc� U �'�C1�j <br /> I / <br /> � <br /> ' <br />