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--------, . - .,.� _� .__ _._��--- -— <br /> �� Backwater Pi•evention Device Rebate Program <br /> �iw�,-._ Rebate Application Form <br /> :�,.�„ <br /> -- �`-J _ _ _ — — _ _ -- — <br /> Property Owner Name: _Lf^� �5 f�w5_ ____ _ ____ <br /> Installation Address: �_ rD�v�4� 5_�__ __.—-- <br /> City:�VEvC'_�_._ Slate: G!.)�-- - 7-iP'_l_D�� <br /> MailingAddress(i/diHerenQ ____ _. ._ ____-- <br /> City. - _----- -- — Stala - -- Zip. <br /> Email' �1��u�5 �rn$y�A m�vw� Phone: �Sf_.aiZJ��GIUU7-- <br /> Tolal Cosl lo Ins�all Device (from confrarlar invoir,e): $__ _ __. <br /> Please veriFy lhe(ollowing: <br /> �J�I am the owner of the property where the backwater prevantion device was inslalled. <br /> �-I worked wilh lhe contractor lo determine the location for ihe backwater prevention dnvice and <br /> understand lha�the decision regardin�lhe iocation of ihe device was mine. <br /> �My contractor instrucled me how to access, inspect, and�namlain the device. <br /> � I unnerstand that I am responslhlr. for maintaininn ihr, hackwaler prevenlion device and keeping <br /> it in good working order, unless il is inslalled in the city righl-of-way. <br /> �I I sell my property, I will make polenlial buyers aware of lhe backwater prevenlion devico and <br /> ihe need to insper.l and mainlain it on a regular basis. <br /> � I am enr.losing all of th� nr.r,essary paperwork (use lhe yellow Rebate Submiltal Checkl,st) <br /> Select from lhe following: <br /> �j 7 he conlractor idenhlied de�wnspouts or olher drainage Ihnes Ihat were connecled lo my sewer <br /> linc(between my house and the inslalled device)�+nd removed, or reroulcd them <br /> (� i <br /> j��7a my knnwledyr., my property has no downspouls or oUier drai�agr. crinner.led to my sewer linr. <br /> (bMween my house�and ihe installed dewce). <br /> n There are downspouts or other drain�ge lines r.nnner,ted to my Sewer linr, (between my house <br /> and the installed device). I understand that leaving Ihese connections creates e risk of flondmg <br /> and I accept that rlsk <br /> . <br /> � <br /> . <br /> i <br /> Signafure _ _____"__�__ Date `�/ r _ <br /> I . . _ _ _ - -- - <br />