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.,,. __. �... <br /> _, ..�.. _ <br /> 3 � � <br /> �ackwa��r Preventwon C�e�°i�e F�ebat� Pr�ogr�m <br /> ; �, �ebate �pplica�tior� F�rm <br /> PropertyOwnerName: ��2(L`� !f'�-}6/��J I.,��",�Ti�-i� f�H��"r_C'r <br /> ' Installation Address: �"��`�"� �����"'� ��- � <br /> ', City: ��� 2�;�- State: W� Zip: ���0`� ' <br /> Mailing Address (if ditferent): ' <br /> : City: State: Zip: ' <br /> � Email_ ��(�-�i Q�>��-�l C.�-✓`-t�J I l_.,, �_-r��M Phone: (���6) ��� � �ti�.�-'� <br /> Total Cost to install Device (from contracforinvoice}: $ � 3�� � 1 � <br /> Ptease verify the following: <br /> � I am the owner of the property where the backwater prevention device was installed. <br /> �� I worked with the contractor to determine the location for the backwater prevention device and <br /> ' understand that the decision regarding the location of the device was mine. <br /> ', � My contractor instructed me how to access, inspect, and maintain the device. <br /> ', �'1 understand that I am responsible for maintaining the backwater prevenfion device and keeping ' <br /> ' it in good working order, unless it is installed in the city right-of-way. <br /> ', (�If I sefl my property, I will make potentiai buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> ,�' I am enelosing all of the necessary paperwork (use the yellow Rebate Submittai Checklist). <br /> Select from the following: ', <br /> ❑ The confractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> ', line (between my house and the instaUed device) and removed, or rerouted them. <br /> �' To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my hause and the installed device}. <br /> , [❑ There�re downspouts or other drainage [ines connected to my sewer line (between my hc�us� <br /> ' and the installed device�, i understand that[eaving these connections creates a risk of flo�ding <br /> and I accept that risk. <br /> ����� � ._ _.._--.� <br /> , _� <br /> , ,. <br /> � <br /> �-- ' I <br /> Signat� �..:'�—���" ate 7�,�G�� � �.�., <br /> �� � <br />