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i <br /> � <br /> � Backwater Prevention Device Rebate Program ; <br /> Rebate Application Form I <br /> i <br /> � --- _ -- - � <br /> Property Owner Name _ [������ n(ti1�� J <br /> -- —`-t".`"-- —� <br /> Inslallation Address I��z, CCd41. Jl • _ _ � <br /> — ---_ � <br /> , <br /> � � I <br /> Ciry --�� :a�cft - --State .Wt�} Zip_ ,t-O ' � <br /> 1 <br /> Mailing Address(il drlferent) <br /> I <br /> City _ State. --- --Zip- — ------ � <br /> � [ria�l. �yvNS� J��?�G_DIn��1�.�on� _Phone ��/ui Sor 1oBo � <br /> � <br /> Tota� Cost to Install Devce (Imm c�ntrecto�invoir.e)' $ ____ _ _ ___ ' <br /> � <br /> 1 <br /> `- — _ _ _ . � <br /> Please verify the following: j <br /> � I am the ewner of Qie property where the backwa!er prever.hon device was installed � <br /> [v) I worked with t^.e contractor to determine the location tor the backwa;er preve�tion device and i <br /> underst3nd that the decision regarding the locat�on o!lhe dewce was mine. <br /> �My contractor ms!ructed me how to access, inspect, and mainta n the device `+ <br /> �I untlerstand lha�I am respnnsible for mamtaining the bacVovate�prevention device and keeping i <br /> d in good wo�king order, unless it is installed in the aty right-o6way i <br /> ��i I seil my property, I wdl make potentiat buyers aware of Ihe backwater prevenhon devir.e a�d � <br /> thc necd to msper.t and m�intain il on a rr.gular basis I <br /> �I am enclosing all of the necessary papenvork(use lhe ye!low Rebato Subrnitla' Checki:stl � <br /> i <br /> Select from the following: � <br /> �The conlractor itlentified downspouls or nther dram2ge Ihnes ihat were connected to rny sewer � <br /> hne(between my ho�se and the inslalled device) and removed, or rcrouted them <br /> i <br /> (�To my knawledge, my property has no downspouls ni oQier tlrainage connPcted to my sewer hne � <br /> (benveen my house anA the mstallr.d dewce) <br /> ( <br /> � There are Aownspouts or o!her dra�nage Imes connecled to my sewer hne (between my house ! <br /> and the instaqed device) 1 understand tha!leaving lhese conner.fons creates a iisk oi(Inod ny � <br /> and I accept thal risk <br /> � <br /> /�//��/ I <br /> Signafurc _ ���� K��,'� — Dafe /fr/T"� _ � <br /> (/ - - , <br /> 1 <br /> � <br />