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. . . . � . � <br />I, . .. � , <br />,; <br />;! • <br />�: . <br />�� Backwater Prevention Device Rebate Program <br />�� � �w�,,.,. Rebate Application Form <br />�,.�„ <br />i <br />t <br />. <br />� <br />Property Owner Name: <br />InstallaUon Address� <br />cfry: �-[ �I vr_�f— <br />�haiung Address (if dilferenQ: <br />City: <br />�. �9n., t � <br />State: � �"L � z�P: 4 b� r/ <br />Stale <br />Email: Ppone� ( ) _ <br />Total Cost lo Install Device (Irom confracfor mvorce): 5 �-'��' vG' �°v <br />Ploaea verffy the (ollowing: <br />�am tne owner o( the properry where the backwater preventlon dovlce was mstelled. <br />�'C <br />�wofked with the coMractor to delertnine the lo��.tion (or the backwater prevenUon dehce end <br />�ndaretend ihat Ihe decisbn reyarding Uie loca�'r�n of the devlce was mine <br />My contractor mstructed me how to eccess, Inspect, and mairnaln tho device. <br />.�understand that I am r�ponsibie for mvintaining Ihe backwater preventlon device and keeping <br />� U in, goal working order unless it is instalkd in the city nght-of-way. <br />�f I sell my propeny, I v:lll make potenual buyer5 aware ol the baclnvater prevenuon device and <br />�e need to inspeCt and malntain it on a repular 6asls. <br />I am enclosing all of the necessary paperN�rk (uuo tho yollow Robate Submitlal Checklist). <br />Selact from the tollowing: <br />❑ The contractor idontihed downspeuts or othor drainage Ilines tha� were connacted lo my se�ver <br />�� {beMleen my house and lhe instalted dEwce) and removed o� rerouted them. <br />To my knowledge, my property has no downspouls or other dralnage Cnnnated to my sawer ilne <br />.. (botwoon my house and the ins4allod dovico). <br />❑ There are downspuuls o� othar drainage Ilnes conne�te0 to my sewer Ilne (between my houae <br />and the Instalted device), I undersland that leaving these connecuons creatos a risk ot Aoaiing <br />and I accept that nsk <br />.• � � <br />Da(e .`��l � <br />_ : ._ _ _ _'..J <br />