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"_�_ '_ _ .__..__`__-_- __-_-_" _' " '_ ' ' _ _ ' ._ _ __ ___"_ ."_'".��_.�_."_.�_�-���'� <br /> Backwater Prevention Device Rebate Program <br /> E„ Rebate Application Form <br /> __ —__-- -- <br /> IPropert;iOwnerName. /I'�`��t-� �� _-__-_- <br /> Installalion Address' . ��U 2- � �V� <br /> City �VG��'1__--- - S�ale: �W {�—Zip._—l.Ill�- - - <br /> i <br /> ! Mailiny Address (il dil/erent): _____ _ <br /> City — —I- — -- Sla�e — -- Zip:.-— --- _ __ I <br /> [maiP �[KlSO�1 Y.� q�0.l 1 • C�'�_ Phone (�_�����_--- <br /> ./ J - - _ ---- � <br /> Tntal Cosf lo Install DPvir.e (lrom conlnc�or invoice) $._. �,��,3�_(j�_ ____ <br /> Please verify the (ollowing: <br /> �I am the owner of ihe property�vhere Ihe backwater prevenlion dewce was installed <br /> � I worked with Ihe coniraclor to detrrmine the localion (or Ihe backwater prevention device and <br /> undersland Ihal the decision regaidiny Uir. locntion of the device�vas mine. <br /> � My conlraclor insUucted me how to ar,cess, inspecl, and maiMain ihe devir,e <br /> � I understand that I am responsible lor maintammg Ihe backwalcr prevenhon dewce and keepiny <br />� it in yund working orde�, unless d is ins�allr,d m tl�c r.ity right-o6way. <br /> LII II I sell my pruperty, 1 wlll make potential buyers awarr, of the backwaler prevention device and <br /> �� the nrr.d to inspec� and maintain il on a re�ular I�asis. <br /> '�4 I am enr.losing all of �he nvor,essary papervmrk (use �he ycllow Rebn�r, Submillal Checklis�). <br /> �� <br /> Selecl (rom lhe (ollowing� <br /> I� The r,untracior idr,nlilir.d downspouls or uthr.r drainage Ihnes that weie connecled to my sewer <br /> hne (';ctwr.en my hnuse and Ihc installwd devic�)and icmoved, or rerouled thern. <br /> � ) To my knawledyr., iny properly heis no dnwnspauls oi nther �Irainaye connr.cled lo my sev�er linr. <br /> (belween my house and ihe installed device). <br /> � � i here are downe,pouts or other drainaye Gnes carn�er,lec' to my sewcr line (betwer.n my house , <br /> and Ihe m;�alled devicu). � understand Ih,d lenwng ih�ese conner.li�ms r.rc�ales a risk o(Ilooding I <br /> and I;ir,cepl�hal risk. <br /> Sirynafure _ �_ � Dafe ��1 � � b � I� <br /> �, �. <br />