2111 LOMBARD AVE 2016-01-01 MF Import

� � i Backwa+zr Prevention Device Rebate Program ' Rebate Application Form I I - i Property Owner Name:�'��✓��_(�,�i✓\,_ _ I �1 1 I I Installation Address: d-- �,,L�^pM 'Dr' f'c�'l ! City: �y�4�/b State: ��_Zip:__1 � I IMaili.�g Address(ifdifferenf)�� I�__,_. I7.��L�P,,.,�_,��r2. i City: �Y �s'-ti/� State: L✓✓�1 Zip: � k1 U/ i I E��aii: �c�m� i Ch(� � /�'I r ti) � CO/��l Phone: (y2�j 3�9" ��IZ � Total Cost to Install Device ((rom contractorinvoice)� $ ,I . I IPlease verify the fallowing: f� I am the owner uf the property where the backv+ater prevention device �vasinslalled. i i � I worked with ihe contraclor to delermine the location for,the backwater prevention device a�d understand that the decision.regarding the location of the device was mine. I (� My contractor instructed mt •,v lo access, inspect, and maintain the device. ; [� I understand that I am.respo.isible for maintaining the backwater prevention:device anil keepir,g - Iit in good working ortler, unless il is'installed iri the cit'y right•of-way. (j�] If I sell my property, I will make potential buyers aware of the backwaler prevenlion device and the need to inspect and maintain it on a regular basis. � � I am enclosing all of the necessary papenvork(use the yellotv Rebate Submittal Che�klist). Seiect from the following: � i ❑ The conVactor identified downspouts or other drainage Ilines lhat were connected to my sev+er ; line (belween my house and the inslalled device)and removed,or rerouted them. '� � To my knowledge, my property has no downspouls or olher drainage connected to my sewer line i (between my house and ihe installed deyice). ❑ There are downspouts or othcr drainage lines connected to my sev�er line(between my house and the installed device). I understand thal leavinc� these connections creales a risk of ilooding Iand I accept lhat risk. � / ' �/y�- � Slgnature .��/ Date I �� I i I I