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uuituizuio a:aa rm r�,u azoa7neaon+- e �F� uooiiuvua � <br /> ! <br /> � <br /> I <br /> Backwater Prevention De�ice Rebate Program <br /> � l2ebate�Appiication Form . <br /> Property Owner Mame: � <br /> i <br /> InslallaNan Adtlress:�C� �_n�-�,�n�/, �� � � <br /> �'ry'-�� sfale: f.aY� zip:�.F'J-Z�! -- • <br /> h1alling.Addresa(BdryerenQ: ' <br /> CIH: St�ta: ' <br /> ��:Zlp: ; <br /> Emeil: <br /> � Phone:(2A� l1f.Q_�-' � �f . . <br /> 7otel Cost WJnstall Device(fiom confractorimroice): 5 <br /> � <br /> Pleasc vcrilythe Following: <br /> (��am the aaner of the property'where the b�ckivaler p�evention devico was insteiled. � <br /> ❑' I�tior}ced wtth ihe contractor to detertnine the location tor.the backvra�e prevenllon device atld <br /> uudersta�d thafthe decision fegardirtp tho loption of the�evice was mine. • <br /> (�tdy contracmr Nstructed mehow to ac,;ess, inspect,and me..;ta;n ifie device, � <br /> [] I-understand that I am responsible for maintaining thc backwaterprevenfion device and kerjping <br /> it In good wo�}iing order, unless k is inslalled in 1he city.Fiyhhof•ivay. ' i <br /> �y �f 1 sol!my proGarty, I wJll make poten4al buyers aware of the backwater prevention devlce anG I� <br /> �t e need(o inspect and maintalrti�t on a regula�basls. i <br /> am enciosing oll of the nocesse � <br /> _ ry pape�work(use the qellow.Retiate SUpmiftai Checklisf).. <br /> Seiect.from the f6(lowing: i <br /> �;The contracior identifleii downsp�uts prother drainage Ilinoc that wem connected Io my se�vet � <br /> " ' line(6ehieon myhouse and Ilie:iristalled deviu:).��d removetl,orrerout�3d�hem. I <br /> �To rrry knawledpe,my property has no downspouls or other drdinage connedetl to my sower Pne'- j <br /> ` -(beN+een.my housC and Gie mstalled device). _ <br /> - � <br /> � 7hore are downspouts:or dlher dreinageJines conneded to my 3ewer Iine{belween my house ' <br /> and the inst�lled deu'ce).'(unde�sl8nd that leaving these conne�iions createsa.nsk of flooding ; <br /> andl ncc:ept thatllsk. <br /> f� 5lgnature_, �;�L ' <br /> ,_,. <br /> _ <br /> Date O �� 7� ' <br /> �. . . <br />