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i <br /> � <br /> ° ; <br /> /� backwater Prevention Device Rebate Program ' <br /> �\�'F,�,. Rebate Application Form ' <br /> .�- - � <br /> / � � <br /> Property Owner Namo: �(�''t�l G�19� lilril/1 t�✓C' �/ <br /> Installation Address: I � I _I Z '�' )� _ ; <br /> Cily: Y'����� .1� Slate:__�/��Zip: �G�Z��� <br /> I MailingAddress (i(diHerentJ: _ <br /> � City: State: Zip: <br /> Email: ' C 't_(',4�Ah ��'��r;_. � "In'� Phone:(YT�j 2r� -SZJY . <br /> Total Cost to Install Device((rom conf�aclorinvoice):$ a"1��� �b�d� <br /> Please verify the following: j <br /> �am the owner of the property where the backwater prevention device was Installed. I <br /> ��vorked with the contractor to delermine the location(or ihe backtivater prevenlion device and <br /> undersland lhal the decision regarding the location of lhe device was mine. <br /> [�My contractor inslrucled me how to access,inspect, and maintain the devia ' <br /> [�'I undorstand that I am rosponsible for mainlaining the backwaler prevenli�.�device and keeping � <br /> il in good tvorking order, unless il is inslalled in the city righl-of-way. <br /> �' If i sell my properly, I will make potential buyers aware of the backwa�er prevenlion device and <br /> lhc need to inspect and maintain il on a regular basis. <br /> � I am enclosing all of Ihe necessary paperwork (use the yellow Rebale Suhmitlal Checklisl). <br /> Select from the following: <br /> ❑ The contraclor identifiod downspouts or olher drainage Ilines that were connected to my sewer ' <br /> line(bet�veen my house and lhe instailed device)and removed, or rerouted them. <br /> i <br /> [�To my knowledge, my propeAy has no downspouts or other drainage connecled to my sewer line � <br /> (between my houso and the inslalled device). <br /> (-] There are downspouts or olher dralnage lines connected lo my sewer line(between my house j <br /> and lhe installed device). I understand�hat leaving Ihese connecAons creates a nsk of Oooding ! <br /> and I accepl that risk. <br /> � �/J � <br /> �� / �� g � - �'/ �i <br /> Signature � Dat � <br /> � <br /> I <br /> i <br /> I <br />