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� <br /> Ba�kwater Prevention Device Rebate Program i <br /> Rebate Application Form <br /> ; <br /> I <br /> Property Owner Name: � C i? ��'7�Z`T � <br /> Installation Address:_ � G � _ C,^�S � <br /> City:�Vr�17�v� Stale: �>�( Zip: �7' c`�. �( _ <br /> Mailing Address(rf difTerenQ:1�10 �� �j�i� � .�;� ��,� �� � <br /> Cily: 71 C�.+i' ( �7�� Slate:�1�_Zip: ! � �7 S ' <br /> Emaii:� C C/_I'7 rrl�r/_-r . ` � �,'to c— �.� Phone: (Y�5)�`> � ?, &� , <br /> I <br /> Total Cost to Install Devicc(fiom r.onfnctorinvoice):S�, � )� . `" j <br /> ---- ' <br /> Piease verify the following: � <br /> I am the owner of the property where the backwater preventlon dovice vras installed. <br /> 1 worked with the contractor to determine the locafion for the backv.�ater pre�ention devica and <br /> understand that the decision regarding the locatlon of the device a�as mine. <br /> [t�A1y contractor insiructed me how to aaess, inspecl, and maintain the device. ! <br /> �I understand thal I am rP.sp^�-ibfe tor maintaining the 6activ�ater prevenlion device and keeping � <br /> d in good ��,oricing order, unless it Is inslalled fn ihe cfty rigM-of•way. i <br /> [�If I sell my property, I will make polential buyers aware ot tlie backwater prevention device and <br /> the need to inspect and maintain II on a repular basis. � <br /> [)�I am enclosing oll of Ihe necessary papenvortc(use�he yelloe�Rebate Submidal Checklisl). i <br /> Select from the following: 1 <br /> i <br /> ❑ Ttie con!rector idenlified downspouls or other drainage Ilines that were connected lo my se�ti�er <br /> line (betvueen my house and the installed device)and removed, or rerouted them. <br /> % � <br /> L""� To my knoe�ledge, my property has no downspouLs or other drainago wnnected to my sev�er Iine <br /> (betwoen my house and the inslallod devicc). � <br /> [] Thero are downspouis or olher drainage lines connecled to my sewer line(hetween my house � <br /> and the inslalled device). I understand that leaving these connections creales a risk of Ilooding � <br /> and I ar.cept ihat risk. <br /> i <br /> � , � � ; <br /> Slgnaturn��l✓— n Date �� 7 / -S <br /> ��_—_ ' <br />