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Backwater Prevention Device Rebate Pregram <br /> Rebate Application Form , <br /> Property Ownei Name: _ �Y�� M�"1 <br /> Inslallation Address: ��0� ��L/3y /�V�• <br /> Ciry: �l�E77�%j State: G✓A Zip: 9b'Ld/ <br /> Mailing Address (rf dif(erenQ: <br /> City� State: Zip: <br /> Emaie /�/!/SD�/E j!✓v �� <>�1,9/L � (af( __Phone: (y� 23/- />?Z7 <br /> Total Cost to Install Device((mm confrac�or invoice): $ �,�L�l'�� <br /> Please verify the following: <br /> �am Ihe owner o(lhe property where the backwater prevention device was installed. <br /> [�I worked wilh Ihe contractor to determine the location for the bactiwater prevenlion device and <br /> undersland that the decision regarding the location of the device was mine. <br /> �My cordractor instrucled me how to access, inspecl,and mainlain lhe dev;ce. <br /> [�I understand thal 1 am responsible for maintaining !he backwater prevention device and keeping <br /> �t in good woricing order, unless it is inslalled in Ihe city right•of-way. <br /> f!seli my prop�:rty, I will make potential buyers aware of the backwater prevenlion device and <br /> Ihe need lo inspect and maintain it on a regular basis. <br /> �I am enclosing all of the necessary paperv�ork (use Ihe yellow Rebate Submittal Checklist). <br /> Select(rom the tollowing: <br /> ��The conirador identified downspouts or other drainagc Ilines that were r,onnecled to my sewer <br /> line(belween my house and lhe installed device)and removed, or rerouled lhem. <br /> (—J To my knowledge, my property has no downspouls or olher drainage connacted to my sewer line <br /> (belween my house and lhe installed device). ' - <br /> ❑ There are downspouts or other drainage lines connected to my sewer line(belween my house <br /> and the inslalled device). I understand Ihat leaving these conneclions creates a risk of Ilooding <br /> and I accept th� t risk. <br /> i <br /> Signature � I Dafe � <br /> r� � <br />