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_ i <br /> � <br /> i <br /> _ I <br /> � <br /> Backwater Preve�ntion Device Rebate Program I <br /> Rebate Application Form . ; <br /> ; <br /> � <br /> : , "� ; <br /> propeAy Owner Name: �—I 11c.ii,( � ��1/ � <br /> InstallalionAddress: �:�-II L���IUGYU 1 <br /> r ; i <br /> � <br /> Ciry: L��C�f C.�'�- �iate: � �.___Zip; �t �7(�� ( <br /> —�_` ^ <br /> Mailing Address (ifdiKerent) ,-� � I � ���10110���i�1 /4 U�- � <br /> -- - �i�2.0 I � <br /> cicy: _� �r���l L- �ste: U 1 I� "Lip: iI <br /> Email: LI,I�C-��� IU 1 Z ``� GO��CC�'1`1 Phone: (�I�S)�J� -[���{,; 4 <br /> O, 3 � <br /> Total�ost to Inslall Device ((rom confracfor invoi�:e): $ ���O �' i <br /> i <br /> r <br /> PleasE•�eriy the foilowing: <br /> � I am the owner of Ihe property where the backwater prevention device was instailed. i <br /> ! <br /> ��!worked with the coniractorto determine the location far the backv+ater prevenlion device and � <br /> understand that the decision regarding lhe location of the device was mine. ; <br /> [�,] My coni�:�,�c,�nslrucled me how lo access, inspect, and maintain the device. • ! <br /> ��I undersland that I am responsible for maintaining the backwater prevention device and keeping � <br /> it in good workinc order;unless il is installed in the city right-of-way. � <br /> IF I sell my propeAy, t will meke potential buyers eware of the backwater preven6on device and l <br /> tne need to inspect and maintain it on a regular basis. _ y <br /> i <br /> ❑ I am enciosing all of the necessary paperwork(use the yellow Rebale Submittal Checklisq. <br /> Se:�ect from the following: <br /> 1 <br /> ❑ l he contractor identified downspouts or olher drainage Ifines Ihat were connecled to my sewer f <br /> iinc (between my house and lne installed device)and removed, or rerouted them. j <br /> (y�!To my knowledge, my property has no downspnuts or other drainage connecled to my sewer Ilne � <br /> (trehveen my house ard Ihe instalfed device). � <br /> i <br /> ❑ 7here are downspouts or clher draina�e lines wnnectad to my sewer line (between my house ; <br /> ar,d t�ie inslalled device). I undersland that leaving thes�connections creates a risk of flooding ; <br /> a id I aaept that risk � <br /> i <br /> i <br /> signature c !r1Vi�;� W�P � vate �)"� 1" 2U1� ; ' � <br /> `� <br /> � <br /> i <br /> . : ;. , <br /> - . _ I <br /> . <br />