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/� Backwater Preventidn Device Rebate Program <br /> �wi�� Rebate Application Form <br /> �3,.�,, <br /> -- -- - --- ------ <br /> IProperly Owner Name: ��V`I �' � '"^� ���.J�� �� "'_ <br /> Installation Address `5 Z` � t'C�� <br /> i `�.,` ,y ��f <br /> City: X/`��'�T�_ --- State:_ Y��_ Zi�:��� <br /> Ivlailing Addr�ss (i(di(leronQ: _ –_ – — _. -- <br /> I <br /> City _ _ State: . — – Z�� ��j 2 I <br /> Email: _ <br /> ��.�J'���-���������.�F�hone: f �T___JZ��j�" �I <br /> Total Cost to Install Device(lrom confractor invoice): 5_�� p���_._ _ <br /> _---J <br /> Please varify the following: + <br /> I I am the ovmer o(the property v+here the backwaler prevention device was installed <br /> �worked with the contraclor to determine the localion for tiie 5ack�vater prevention device and <br /> undersl�.nd ihat the decision regarding the localion of the device was mine. <br /> � � .contracfor instructed me how to access, inspect, and maintain the device. <br /> [ , I understand Ihat I am respnnsible for maintaining the backe✓aler prevention device and keeping <br /> it i good e�orking order, unless it is inslalled in the ciry right-of-way. <br /> L ; lf I sell my property, I will make potential buyers a�vare oi the backwater prevention device and <br /> Ihc{ eed lo inspect and maintain it on a regular basis. <br /> �[ .I am enclosing all of the necessary paperv✓ork (use the yellovr Rebate Submiltal Checklist). <br /> � Selecl om the tollowing: <br /> I .,L, l l;e conlractor idenhfied downspouts or other drainage Ilines that were connected to my se�ver <br /> ' ,litie etween my house and the insialled device) and removed, or rerauted them. <br /> I �o.iiiy knowledge, my prnperty has no downspouts or other drainape conneclad lo my sewer line <br /> (behveen my house and lhe installed dcvice). <br /> re are dovmspou�s or olher drainage lines conneded to my sevrer line(hetween my houce <br /> i a d the Installed device). I understantl that leavinp Ihesa connections craates a risk of floating <br /> 1�• and I accept thal risk. <br /> Signature �' ` Date_ I� <br />