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i <br /> �,�}� Eiackwater Prevention Device Rebate Program <br /> �'�� Rebate Application Form <br /> w <br /> � <br /> � � V <br /> Property Owner Name: �f (��/� <br /> Installation Address __� ���(fJ'�"_�V E <br /> City:.�(f.Q�Q,,� State: lil/�9 7_ip:_���� �l� <br /> Mailing Address(il dil(erentJ: �.J�J� <br /> Ciry: __ State: Zp: _ <br /> Email: Phone: (7�J)tJ �cJ�L <br /> --- ,r,� �— — <br /> Total Cost to Install Dev�cc (Irom contractor rnvoiceJ: $2� �.C.J��" <br /> Please verify the following: <br /> �71 I am the owner ol the property e�h.ere the backwater prevention device�1�as instalied. <br /> r � <br /> �J I viorked with the conirector to determine the loca;ion for the backwater prevention device and <br /> understand Ihat the decision re�ar�ing Ihe localior o(the device was mine. <br /> �� fvly conlractor instructed me hnw to access, in,pect, and maintain the device. <br /> T <br /> �I understand thal I am responsible for maintaining ihe backwater prevention device and keeping <br /> rt m good�vorking order, uNess it is installed in lh:city righl-of-way. <br /> �II I sell my propeny, 1 will make potential buyers aware ot the back�vater preventior device and <br /> �he need to inspect and maintain it on a regular basis. <br /> �I am enclosing all of the necessary pnpenvork (use Ihe yellow Rebate Submittal Checklist). <br /> Select lrom the following: <br /> ❑ The coniraclor identified dovmspouts or olher drainage Ilines Ihat weie connected to my sewer <br /> line (between my house and the installed device) and removed,or rerouled ihem. <br /> � To my knowledge. my property has no downspouts or other drainage conneGed to my sewer line <br /> (between my house and Ihe ins�alled devicc}. <br /> �_) There are do�vnspouts or other drairage lines connected to my sewer line (behveen my house <br /> and!he installed device). I understand thal leaving these connections creates a nsk of tlooding <br /> and I accepl that risk. <br /> �� ' <br /> ' c 1 4.�Gs+� <br /> � Signafur �.�.�_ Date <br />