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��k�va�er r v�n�i�n ���ri�� Rei�ai� �'r�gram <br />� eb��e Appli�a�i�n ��r-m� <br />Prope�ty (�wner l�ame: � � i�� � ;�. ,�. , ��` �"� � <br />Installation Address: ,�-�C� �{ ��`l �.. (..�v�%� � l� %�" �J�-- <br />City: �"�'�'�'.,.•-�-'-� State: lN� Zip: � �� � <br />Mailing Address (if drfferent): � ( �" � <br />City: � �� State. _ � �_ Zip; �1;1� �� <br />�;.-ry���� ��� � -- �J��, t. Gc�� z ,�,-� ,�a-" <br />Email: �° �%' � Phone: ( �{t�) ��.� '' �� �5 <br />Total Cast to Install Device (from confraciorinvaice): $ <br />� ( <br />Please verify the follornring: � <br />[�' I am the owner of the prop�rty w�tere the b�ckwater pr�v�ntion device was installetl. <br />�' � <br />�I worked with the contractor to determine the lacation for thebackwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />`� My contractor instructed me how to access, i��spect, and maintaii� the device. <br />[� I understand khat 1 am responsible fQr maintaining the k�ackwater prevention device and k�eping <br />it in good wc�rking order, unless it is installed in th� city right-of-way. <br />� If I sell my property, I will make potential buyers aware af the backwater prevention device and <br />the need to inspect and maintain �it on a regular basis. <br />� I am �nc{osing a1l of the necessary paperwork (use the yellow Rebate Submittal Checkiist). <br />Select from the following: <br />❑ Th�e contractor identifietl dc�wnsp�ut� t�r other drain�g� llines'that were cannected-to my s�wer' <br />line (betweer� rtty house and fihe`installed device) and r�moved, or rerouted ti�errr; <br />'�,,.7o my knowi�dge, my property has no downspouts or oti�er�drainage cannected�fio my sewer line � <br />{between my house ana the instalied device). <br />❑ There are dcrwnspoufs or other �rair�age lines conne�ted #o �my serrver lin� {between my house <br />and the installed device). I understand that leaving fhes� connectians cr�ates a risk of flooding <br />and l acc��at that risl�. <br />� <br />, <br />c''`� � ,1 � � � <br />� <br />Signature -''�/� V.� Date � �' � �' <br />� <br />