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� <br /> � ��� Backwater Prevention Device Rebate Program <br /> ' Y�w�,...r Rebate Application Form <br /> :�..�„ <br /> ; - -- <br /> � Property Owner Name�_��j�i1� { Y-/Lrii'!t'N _ <br /> � Installation Address: �/.� LtJP /1�6 Cr _�a/�� _ <br /> � � .�, . <br /> Cily: � P_ Slate: �1�, z�P: q.�'�a % <br /> , Mailing Address (r(dilleren(): 7T Z� �-�KO� rG /�� <br /> � '� �.���7d <br /> City:�/t ✓v� __ State:_f�U�Zip: <br /> Email: -� �/1'J✓/1�• �n"'1 Phone:(,�) 6 J 4— /��� <br /> i Total Cost lo Inslall Device(Irom confractor invoice):$ ���� � �� <br /> IPlease verify the Tollowi�g: <br /> � � am the owner of the property where lhe backwater prevention device was Installed. <br /> Iworked with the conlractor to determine Ihe localion for ihe backwater prevention device and <br /> � �/ <br /> �understand that the decision regarding the location of the device was ml�e. <br /> i �`S'�L My conlraclor inslructed rr,e how to access, inspect,and maintain the device. <br /> ! <br /> i I understand lhat I am responsible for maintaining the backwater prevention devlco and keeping <br /> it in good working order, unless it is installed In the city right-of-way. <br /> I t I sell rny property, I �vill make polenlial buyers aware o(Ihe backwaler prevenlion device and <br /> ! the need to inspecl and mainlain it on a regular basis. <br /> i <br /> � �am enclosing all of lhe necessary papenvork (use the yellow Rebate Submittal Checklist). <br /> i <br /> Select from the following: <br /> � <br /> I �The conUactor idenlified downspouls or other drainaye Ilines lhal were connected to my sewer <br /> I line (between my house and the installed device)and removed, or rerouted them. <br /> ; ❑ To my knowledge, my property has no downspouls or other drainage conne�led to my sewer line <br /> � (behveen my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line(betvreen my house <br /> and the Insf�lled device). I understnnd thal leoving these connections creeles a�isk of Oooding <br /> I and I accept that risk. <br /> I� ate � � �" <br /> � Signafure J� <br /> � <br /> \ I <br />