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, <br /> � <br /> I <br /> � <br /> Backwater Prevention Device Rebate Program i <br /> � Rebate Application Form <br /> , <br /> � <br /> c <br /> � IJP�'�Y� ��T (�C'�� i <br /> Property Owner Name: ` <br /> Installation Address: 0 � � �/ j <br /> _..,.` II State: �� `-'��_�J� f <br /> Clly:�l�4� _ Zip: � <br /> h1ailing Address (i(dilferent):�_1 J�Y� �c�-SQ� — _ � <br /> �NC -V�_ s.laJ�1� I <br /> Ciry._' State: Zip: �}�cJ�JCJ j <br /> Emai!:� aT� �:, �b GzC�N(Y�At�I'J�'_U'rfEt�Phone:�� asx_�y� � <br /> Toial Cost to Install Device(from confraclorinvoiceJ:5���.'�P � <br /> I <br /> _�_— � <br /> Plcase v�trify the tollowing: �{ <br /> � I am Ihe owner of lhe properly where the backwater prevention device was Inslalled. i <br /> �I worked with Ihe wntraclor lo detormine lhe localion for tho backwaler prevention device and i <br /> undcrstand that the decision reyarding the localion of the devicc was mine. ( <br /> f <br /> �� My contra�ior instructed me how lo access, inspect, and mainlain the device. 4 <br /> [3f� I undcrstand Ihal I am responsiblc for mainlaining Ihe backwater preventiDn device and kecping � <br /> il in good working order, unless it is Inslalled in the city righFof•way. i <br /> � If I sell my proparty, I will make polential buyers aware of lhe backwater prevenUon device and � <br /> the need to inspecl and maintain il on a regular basis. ' <br /> �'� I am e�closinr,all o(tho necessary paperwork(use the yellow Rebale Submlllal Checklist). � <br /> Select from the following: <br /> ❑ The contraclor identified downspouls or other drainage Ilines Ihal were connecled to my sewer <br /> 6no(bclwecn my house and Ihe inslalled device)and removed, or rerouled lhem. <br /> � To my knowledge,my property has no dovanspouts or othor drainage connectod lo my sewer line <br /> (hetween my house and rhe installed device). <br /> ❑ There are downspouts or other drainago lines connected lo my sewer line(between my house <br /> and the inslalled device). I undersland Ihat Ieaving Ihese connections crealas a risk of Oooding <br /> andl acceptthalrisk. <br /> Signatm� + '�_ Oafe � � � ��7 <br />