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i <br /> I <br /> I <br /> �� � Backwa2er Presention Device Rebate Program <br /> �� Rebate Application Form <br /> �— ------- --- — I <br /> j Property Owner N�ne� � /'� G{.(I�i'LQ.� �� L'ei <br /> iInslallation Address. ��n ; " 1'I� .�� <br /> � C�ry ��j{���— _State v�'1'r _ZiP: '"I V vt1 � <br /> ' i�^ailing Address (i1 dillB/enI).__�1� I V I{/�G'LC�t�S f7 UL <br /> ICfly. �Vt'/1 4/� Slale._� -� 7_ip._. '"1"1D�Z � �I -1� _ <br /> � Emaii. �it (J(:� � _�f hone. ��� ��D � <br /> i 7ota1 Gosl to I��stall Device (Irom con ractor invoice): S __ <br /> I <br /> Please verify the following: <br /> � t am the o�^�ner of Ihe property whe�e ihe Gar.k;va(er preverLon dewce v:as installed. <br /> � I worked virth Ihe con�ractar to determine li�e Iccaiion (or Ihe backv�ater nrevenlion device and <br /> unde;stand Iha!�he decision regarding lhe localion of lhe device was mine. <br /> (� �.iy coNractorinstrucled me how to acce;s, �nspecL and maintain the devir,e. <br /> i�j I undersland Ihat I am responsible for mainlaining the oackwater prevention dev;ce and keepirg <br /> it in good w�iking order, unless it is installed in Ihe cily right-of-�vay. <br /> �] If I sell my property, I will make polential buyers aware of the back«•aler prevenhan device and <br /> the need to inspect and mainlain il on a iegular basl>. <br /> 7�� I am enclosing all ot the necessary papenvork I�i:;e Ihe yello�:i Rebale Submittal Checklis:). <br /> Sciect (rom lhc (ollowing: <br /> � � The ;;ontractor idenhfied dov:nspoul5 or othei dramage Ilines lhat werr connected tn my sewer <br /> linc (�elvreen my house and Ihe inslalled device) and reir,oved, or rerouled lhem. <br /> [.K� lb my knowleCge, my property has no dovanspoids or olher drainage connected to my sewer line <br /> (belv�een rny house and ihc inslalled Aevi�r.). <br /> I � I herr are do�h�nspouls ar olher drainage lines connecled lo my sewer line (belween ;ny I�ouse <br /> and Ihr. instrdled dewce). I undr�rsland thal leaving Ihese conner.fions cieales a risk af 1loodinu <br /> and I accen� that risb. <br /> Signafure����� Datc !0- /!� -• .'�A/� <br /> o ' 0 <br />