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ackwater Preventian Qevice Reb�te Presgram <br /> eb�a�e Appli�atian Farrr� ; <br /> , /� , <br /> Property�wner Name: ,�C ��"t-`1!�. � ,�11 ��`'' ����t�,-,.5�' <br /> Installation Adr#ress: �. ,,� �.G��17��r���l,.��� <br /> City: �������� 5tate: ly�'; '�� Zip: <br /> Mailing Address(if different): <br /> City: State. Zip: <br /> Email: Phane: ( ) <br /> Total Cost to Ins#all �evice{from contractorinvoice): $ <br /> Please verify the faEtowing: <br /> �[y�l� m the owner of the property where the backwater pre�ention device was installed. <br /> worked with the cantractor to determine the location for tha backwater preventian device and <br /> understand that the decision regarding the lacation of the device v+ras mine. <br /> �My,..contracfior instructed me how to access, inspeat, and maintain#he device. <br /> �understand that l am respansible for main#aining the backwater prevention device and keeping <br /> it jn good warking c�rder, un(ess it is installed in the city rit�h#-af-way. <br /> � If I seil my property, l�+vil1 make potential buyers av�are of the baekwater preuen#ion device an� <br /> the need to inspeet and maintain it on a regular basis, <br /> (�I am encfosing ali af the n�cessary paperwork(use the yellow Rebate Submittal Checklist}. <br /> Selec �fram the folfowing: <br /> The confracfor identifed downspouts or other drainage flines that were connected to my sewer <br /> line(between my house and the installed d�vice) and remo�ed, or rerouted them. <br /> �o my know{edge, my properry has no downspouts or other drainage connected to rny sewer line <br /> (betwe�n my house and the installed device). <br /> [�Ther� are downspc�uts ar other drainage lines canneated to my sewer line(between my hause <br /> and th�o irrstalled device). ! understand that leaving khes�cc,nnecfions creates a risk of ffooding <br /> and ! accepk that risk. <br /> �r�` � � , _j .. � <br /> Signatur � J�afe <br /> �� <br /> � <br />