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i <br /> � Backwater Prevention Device Rebate Program <br /> I Rebate Application Form <br /> PropertyOwnerName: �u5� (i • C�O/-�%Z..��S <br /> � Inslallalion Address: 2 � � S �57� .Sl���% <br /> � � <br /> � City: �✓�IZcT/ —State: �A ZiP 8 20 {' <br /> i <br /> i <br /> ! Mailing Address(il di(ferent): __ <br /> � Cily: --. _- Stale: _ - _-—Zip: , <br /> ! �oS<`. , �7 � <br />' i EmaiL• �N��.%r�,�-h(GI C�rj41���one: (� �� / �(�4'Z� � <br /> 1 I Total Cost to Install Device ((ram confractorinvolce): $ pc.�_�'Oa___. ____ <br /> � <br /> iPlease verify the following: <br /> i � I am the owner o(the property where the backwater prevenlion device was inslalled. <br /> I � I worked with lhe contractor to determine the location for the backwater prevention device and <br /> i understand that the decision regarding the location of the device was mine. <br /> � ❑ My contracl�r instructed me how lo access, inspect, and maintain the device. <br /> i <br /> � �c I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> , il in good workin� order, unless it is installed in the city right-of-way. <br /> � btJ If I sell my property, I will make potential buyers aware of the backwaler prevenlion device and <br /> i the need to inspect and maintain il on a regular basis. <br /> I ❑ I am enclosing all of Ihe necessary paperwork (use the yellow Rebate Submi�tal Checklist). <br /> I <br /> Select from the following: <br /> I <br /> i ❑ The contraclor ide�itified downspouls or other drainage Ilines tha�.were connecled to my sewer <br /> line (between my hnuse and the inslalled device) and removed, or rerouted them. <br /> i �� � To my knovAedge, my property has no downspouts or other drainage conner,ted to my sewer line <br /> � (belween my house and Ihe installed device). J <br /> ; U There are dovmspouts or other dralnage lines connected to my sewer iine(between my house <br /> I and the installed Aevice). I understand lhat leaving these connections creates a risk of(looding <br /> I and I accept ihat risk. <br /> j <br /> � � / ��� /.��� � <br /> j Signature ��"'�–l7� "��� _Datc � 0� �� � <br /> I � I <br /> I t <br /> � � <br />