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Backwater Prevention Deuice Rebate Proyram <br /> d Rebate Application Form <br /> - �, r� �[- - <br /> Property Owner Name: '��5c'J��177" I _ �l�l+ ��7✓�� <br /> _ _ ____.__ <br /> Ins(allalion Address: _ / L2 � � � (t �>/ . <br /> --- <br /> _---- ----- _q <br /> City: _ Uu�"�r i� - _ _ Slolt:: ,� Zi��: / � <br /> Mailing Address (i(dilfcrenfJ: <br /> City:—.— Sl.dc: .�_ _...---��P�--- -- ... <br /> Email: - -- (�honc: ( ).-- - - -- <br /> Total Cost to Install Device (Irom conlradorirrvoir,eJ' $ <br /> Please verify the fallowing: - <br /> �am lhe owner of�he properly�vhere Ihe barNwatr:r prevention devicc was insl;illr.d <br /> �{ I worked viifh the contraclor to delermine Ihe lucation (or Ihe backwaler p«�vention devir,e and <br /> understand Qiat Ihe der.ision rr,garding ;n� io�;,o<,�,or in� �i����� W�; ,,,;,,�. <br /> [� My conlraclor inslructed me how lo acr,ess, inspecl, and maint.�in Ihe devir.r.. <br /> [�I undersfand �hat I am respon:;ible lor mtiinlaining the bar,kwaler prevcnlion devicc �nid keeping <br /> it in good v�orking order, uNess it is inslalled in lhe city right-of-way. <br /> [��If I sell my propehy, I will make polc;nlial buyer; aware of Ihe hackwaler prr.venGnn devicr�and <br /> Ihe need 10 inspect and rnaintain it on a rcyuiar basis. <br /> (.�f"1 am enclosing all of lhe ner.essary papr,rwork(usc lhc yellow Rebale Submill;ll CI1Cf,RI15I� <br /> Scler.l (rorn lhe following: ; <br /> � <br /> �.� �Rie conlractor idenlifiCd downspouls oi olhr,r drainage Ilines Ihal wem connr.��,ie�l lu niy sewei � <br /> line (br.�wce� 07y housr. ��id lhe inslallcd device)and removr.d, or rcroided Ihcm � <br /> [�To my knowledge, my properly has no dnwnspouls ur ofher drainngc conn�x:led li�ury ;cwer line I <br /> (betwecn my housc and lhc inslalled dr.vir.c) � <br /> � ] I hnre �ire downspou�s or ollicr drain�iyc lines connr,ded lo my ;ev�ci In�r. (I�clwucn ury hniise <br /> and Ihe installed device). I under:;l�ind lir,d leaving Ihr.se connuchun:,::renles;i ie:k uf Ilnuding � <br /> ind I �cr.ept Ihal risk. � <br /> � <br /> .� /^' I <br /> Signahuc �.R.t �c.C� Ordc ���-�S� � <br /> ___ I <br /> �— - ---- - -- � -- - — ------� <br />� i <br /> ! <br /> I <br />