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1 �.�.-�_ �.�_� ��_ _ __. ��_.�. <br />� . . . . . <br />L <br />� <br />� � <br />� <br />; <br />�' <br />`�. <br />Backwater P�evention Device Rebate Program <br />Rebate Ap�lication Form <br />?roperty Ovmer <br />In9t8118ti0n Addfe55: �1�.(.� (�� � _J"�V-�. ^ <br />City: C�.1�F�� Slate: � %�" Zfp:��� ` <br />L4eilin� Address (if dilfo��nt): ��A-tv�Q_ . <br />Cit��, State: Zip: <br />Email: Phone: ( ) <br />Total Cost to Inslall Devicc (from connactor mvofco}: 5._ 2�� f <br />Pleaeo vorify the (ollowing: <br />[!f I am the owner of the property a�here lhe backvreter prevent�on device was mstailed. <br />. •�I worked with the contractor to ootermma the locallon for the backwater preventlon tlevice an� <br />u�dersland Uial lhe decision regaiding the locatlon of the davlce v�as mine. <br />• �`j My contrector instructed me how to access, inspect, and malntnin the dehce. <br />�f understand that I am responsible for maintaining the backwater prevenUon device and keep ng <br />It in good wrorking order, unless it ig Installed in the cily nght•of-way. <br />'K`j� If i sell my properc�, I wlll make potenlial buyers aware oi the backwater prevention device and <br />the necd lo inspecl an: malnlain it on.a mgular hasis. <br />�) I am entlosing all of :ho nocaocary popernbrk (use thc �cllc.v Robatu SubmiUol Checkllet). <br />/— <br />Sotoct 1rom lhe tollowing: <br />, • tl 11 The conU�iclor ldentified do�vnspouts or other drainage Ilines Ihat were connecic�cl lo my sewer <br />�' line (betH�ecn m'y house a�d the mstailed dewca) and removed, or reroutad Ihem. <br />� To my knowledge, my properry has no ao�mspculs or other dralnage connected to my se�.ver Iine <br />(between my house and tho inslalled device). <br />•� <br />❑ There are dcrwnepouls or ou�er drainago Ilnes connectetl to my sovier hne (between my house <br />and the instal(ed davice). I undersland Ihel leaviny these conneclions crea�es a risk o( flonding <br />and I accept that risk. <br />. s � , <br />Slgnatul� '"'ti`^' � ��l � • � .Ut�.- _ Dete -- � - <br />: ! . -,��� <br />� . � , � <br />