1302 GRAND AVE 2016-01-01 MF Import

i i � Backwater Prevention Device Rebate Program i Rebate Application Form I , I J ; Property Owner Name: _ /(��h ��n h�i� � �G�i� .� r�"UG�� ; Installation Address: �� G�/� .�}71t-�- � i ��i�-J( 4 City: � U Pr e � Stafe: Ln//� Zip: /, ; �vio�!ing Address (ildllferent): � City: State: Zip: � Email:� 7 G � � �• �or-+ Phone: (�/.,1� 35��l. /5�.�. ! Total Cost to Install Device (Irom contractor invoice):S ��yy S� � t'S-�i.�c�Cl � i Please verity the following: ! i �m the owner oi the property where the back�vater prevention device was installed. j ! �worked with the contractor to determine the location for ihe backwaler prevention devico and � understand that the decision regarding tha location �f Ihe device was mine. ; i ��'My contractor instructed me how to access, inspect, and maintain the device. � [I understand that I am responsible for malntaining the backwater prevenlion device and keeping 1 it in good working order, unless it is instalied in the city rlght•of-way. j i �If I sell my property, I will make potential buyers aware of the bacfavater prevention device and the need to inspect and maintain it on a regular basis. ; I [�T am enciosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). f Seiect from the following: � i ❑ The contraclor identified downspouls or other drainage Ilines thal were connected to my sewer S line(belween my house and the i�stalir.d device)and removed, or rerouted them. �To my knowledge, my property has no downspouts or other dralnage conneeted to my sewer line ; (behveen my house and the instalied device). � ❑ There are downspouts or other drainage lines connecied to my sewer line(beM�een my house � and ihe installed device). I understand that leaving lhese connections creafes a risk of Flooding , and I accept that risk. ; f Signature L� Date .� � � I L�� r � t � I !