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<br /> �� �� Backwater Prevention Device Rebate Program � �'.` :. � � ' �
<br /> !. �w�..._ Rebate Applicatic�ri:Form� . : , . ; . . � I
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<br /> � Property Owner Name: ' . . ' � ,
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<br /> Installetlan Address: _��� �� '" ��) — ' .` _ . • � . . ! . . I I
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<br /> • Ciry: i 3,fL� Stale: Zlp:• �
<br /> � Mailing�ddress (il ditfmm�tJ:.` ' _ J ViMK_. ' . ' � ' � . . � � �
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<br /> City: State: • Zip:. . ,.; ' :' I
<br /> . . : Emall: �(�I��C�I t14�LLLl;l�"� • X Phone: (H�j -1�"7�.5 �., . I
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<br /> Totai Cost to In'stall Device(Irom cont�actorinvoice): 8 � ' L..,JP JLl � ' � "' �� .
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<br /> � Pleaae verHy the following: , . .!� � � �'• .
<br /> ,{�j I am th'e owner of the prcperty ivhene the backwater prevention device was iristalled�' � • . '
<br /> , �worked with Ihe contractoi to determine ihe,iocat(on for,tfie backwater prevention device and •. . , , �
<br /> , u erstand(hat Ihe daclsion regarding,the Iocatbn of the device was mine. � , : ,
<br /> . Mr contractor instructed me how lo ar,cess,.inspect, and maintein the,device.• ',.� • � . • !
<br /> I understand lhat t am responsible for malntaining ihe backwa;_r.prevention device and ke�eping �' • .
<br /> ii in good working order, unless if�is installeJ in tho city right-of-way' "' . I
<br /> �f If I seil.my property, I will make potential buyers awa�e of the baekwater prevention davice and • ' � ' �
<br /> � �� the need fo ins�wr.t and malntein itbn a regular,basis. � . : , , .�.� '' •�'�': I
<br /> • • �am enGosing all of lha nocesstjry popenvork(uae the yellow Rebate 3ubmltWl Checlelist). ,. � : i
<br /> ' - Sulect from lhe following: ' • ,
<br /> � ❑ The'conliactor identified downspouls or other drainage Ilines Ihat were wnnecled to my sewer , � - I
<br /> � line (betwecn my house and the installed device) and removed, or.reroi�led them. ' •••� ' '
<br /> , � To my knowledge, my properry has no downspouts or,otherdrainago connected to rtiy,sewer line � • . �.�, �
<br /> � (betwcon my house and tha inslelled devlce). :�:
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<br /> , Q There are downspauts or omer drainage lines connected to my aeWer Iine(behveen my�house ' . .
<br /> and the Inslalled device). i undersWnd.that leavinp lhose connections creates a risk of(Iooding '� - •
<br /> and l accc�t that risk. .,_ . �'•� � � • • �'
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<br /> � SignaWro Date ����5� . . . ,
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