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� <br /> � ` ' <br /> �,�}� Backwater Prevention Device Rebate Program <br /> I �w��„ Rebate Application Form <br /> � <br /> ' Properly Owner Name�__���A �-1 o u�e f <br /> i <br /> I InslallationAddress: ZI I1 �r�E-�V��Y �' Av'� . ___. <br /> I, City: ��J�/�.�' -. --State: W A Zip: �I �2�1 <br /> � <br /> Mailing Address(i(dilferent): ___._—_ <br /> I Cily: Slate:_ Zip: <br /> IEmail: Phone: ( )__ _ <br /> � Tolal Cust to Inslall Device(irom contractor invoice): $_Z SGG/•� <br /> � Please verify lhe following: ' <br /> i � I am the owner of the propeRy vuhere the backwaler prevention device was installed. <br /> � I worked with Ihe contractor to determine the location for the backwater prevention device and <br /> � understand that the decision regarding the location ot lhe device was mine. ' <br /> i <br /> � � My contractor instrucled me how lo access,inspect, and maintain the device. <br /> � � i understand that I am responsibl?for maintaining the backwater prevention device and keeping <br /> il in good working order, unless it is inslalled in the city right-of-way. ! <br /> I � It I sell my pwperty, I will make polential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain iLon a regular basis. <br /> � �am enclosing all of the necessary papenvork (use the yellow Rebate Submittal Checklist). <br /> I �, Select from the following: <br /> ❑ The coniractor iden�itied downspouts or other drainage Ilines Ihat�vare connPcted to my sewer <br /> line(between mv house�and the inslalled device)and remoaed,or rerouted tnem: <br /> � '� To my knowledge, my properly r�s no downspouts or olher drainage connecled to my sewer line <br /> (between my house and the Insladed device). <br /> ❑ There are downspouls or other drainage Ilnes connected to my sewer line(behveen my house <br /> and lhe inslailed device). I understand lhat leaving lhese connections creates a risk of floodiny <br /> I and I accepl that risk. <br /> � <br /> j Signafure k���""� � Date "L� L'I � 5 <br /> ( <br /> � <br /> � <br /> � <br /> I <br />