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OIBackwater do Rebate Program <br /> L Rebate Application Form <br /> Property Owner Naffl : t 3 <br /> installation Address <br /> CRV: � .._._ ., State_. zip!--Li <br /> Mailing Address(ifdiffemni): <br /> City: State' <br /> r 1 z f c � t Phone, { CL <br /> _ <br /> `fatal Cost to install Device(fsvrn contractor Jr"is oic-e): <br /> Please verify the follo tnS: <br /> l am the owner of the property where the backwater prevention device was installed.. <br /> I worked with the contfa,Jkurto determine the location for the backwater pi,evenG a device and t <br /> understand that the r girding tttH of the d€avict�wr ,a mine, <br /> j fly contractor irr =rtrrt:<,t Pie!rimy to access,inspect,and main in tl r. € ciao, <br /> ] l urrdr e stand that f, r,,...ponribie for maintaining the t3�c�»� ,pff r ,mien device and keeping <br /> it in good working onJ' r,un es a it is Installed in the city right-of-wly. <br /> ] tf!sell my property,I evil€mace potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> El !am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Ch allst). <br /> Select from the following: <br /> The contractor identified downspouts or other drainage Ifir es that were connected to racy sewer <br /> line(between my house and the installed device)and re moved,or rerouted them. <br /> L] To my knowledge.n y property has no downspouts or other drainage connected to my sewer fine <br /> (between my house and the installed device), <br /> , ] "theme are downspouts or other drainage titres connected to my newer Ifrre(t?r»st�veer�my house <br /> and the installed device)_I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> fd <br /> Sfrratrr sr1 I f ., gate <br /> t <br />