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, � . _ . <br /> , � <br /> • I <br /> ! <br /> i <br /> / <br /> . � 6a;,kwater Prevention Device Rebate Program ' <br /> Rebate Application Form <br /> � <br /> i <br /> PropertyOwnerName Y Q�C-Q— � �Y� n�. �� <br /> i Installation Addresr �J a CQ ) <br /> ( � 1 � <br />� �C�-Q..,�j� . �-'V Zi : 1 0 C-�( <br /> I� Cdy. ' '`-� \ State. �__ p_ � <br /> Mailing Address (iI diflerent): <br /> City: State: Zipc � <br /> Email:�O�j.(�nQ���_Nhone:�') ��a-�� I ' <br /> L' 'JYl'�^_� . rSZ- .U v t <br /> Tolal Cosl fo Inslall Dewce (l�om coNractor invoice): 5 2� �G � <br /> Plean�vcri�y the foltowing: ;' <br /> � I am Ihe own�•�� .he property ivhere lhe backwater prevention device was inslalled. f <br /> , <br /> '�1_I worked with Ihe conlractor lo detertnine the localion for Ihe backwater prevenlion device and{� <br /> ''�unders�and lhal the der.isior regarding the location of the device was mine. � <br /> �My conlractor instrucled me how to access, inspecl, and mainlain the device. -, <br /> �[,'] I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> � it in good working order, unless it is installed in!he city right-of-way. ` <br /> �' If I sell my propeAy, I will makc pofenlial 6uyers aware oi the backwater prevenlion device and� <br /> the need lo inspect and maintain it on a regular basis. {� <br /> �C�]] I am enclosing all o(Ihe necessary paperwork (use the ycllow Rebate SubrniUal Checklisl).� <br /> Select irom the following: � <br /> � The contraGor identilled downspouts or other drainag•: Ilinr.s that were connected to my�sewer <br /> line (belween my house and thc installed dev;ce)and removed, or rerouled lhem. �-' <br /> �� To my knnwlr.dge, my property has no downspouts or other drainag�connede.d to?y sewrr line <br /> (belween my house and Ihe inslalled de.�ice). � <br /> �There are dow�nspouts or other drainage lines connecled to my sewer line (1�etween ny housr. <br /> and the inslalled device). I understand�hat leaving these connections creales a risk of fiooding <br /> and I accepl lhal risk. � <br /> � . <br /> Slgnature �'i"�� � Dafe �� ( l <br /> ._... <br /> .. ._ �...-•--�•-i'� <br /> � <br /> �`------- _ <br />