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� <br /> � <br /> � <br /> I <br /> I <br /> �,�� Backwater Prevention Device Rebate Program � <br /> �i��,., Rebate Application Form � <br /> J_.. j <br /> --- , i <br /> �----- i <br /> Property Owner Neme.�ra. L c�_C � u nC h � <br /> InstallationAddress: 1 a6 � MAn�� � ! <br /> I <br /> � � <br /> Ciry: �v�Rer i Stale: W A Zip:�s�a 1 + j <br /> �daiGng Address QI diNerent�: I� d !3 o�Y S a � _( i i <br /> City_=a f n � r v' State: I.✓ A Zip: q � 2� 6 j � <br /> i � <br /> Email: Phone: (4���r1•� y`r� j � <br /> eo � � <br /> T�tal Cost lo Install Device (lrom contractor invoice): 5�_5� i � <br /> , <br /> , j <br /> -- -- - � <br /> i <br /> Piease verify ths following: I <br /> i <br /> �{i I am the owner of the property where the backwater prevenlion device was installed. � <br /> � I worked with the contractor to determine the location for lhe backwa�er prevention device and � <br /> undersland that the decision regarding the localion o(ihe device v+as mine. � <br /> � My contractor instructed me how to access, �nspect,and mamta:n the device. � <br /> � I understantl thal I am responsible for mainlaining ihe backwaler prevention device and keeping � <br /> it in good working order, unless it is instaued in the city nghl-o6way. � <br /> t <br /> �{, If I sell my properly. I�vill make potenlial buyers a�vare ol the backwater prevention device and <br /> the need lo inspect and maintain it on a reoular basis. � <br /> Q� I am enclosing all of the necessary papeiwork(use the yellow Rebale Submltlal Checklisq. � <br /> Select from the f�tlowing; <br /> � <br /> � The con4actor identified downspouls or oUier drainage Ilines Ihat were connecled to my se�ver � <br /> line (hetween my house and Ihe installed device) and removed, or rerouted Ihem. ; <br /> � 1 o my knowledge, my property has no downspouts or olher drainage wnnecled lo my sewer line ` <br /> (belween my house and Ihe inslailed device) � <br /> � There are downspnuls or olher drmnagc lines connected lo my smver line(beN+een my house � <br /> and tlie insfalled device) � undersland ihal leaving these connections creates a risk of flooding i <br /> and I accept that risk. � <br /> � <br /> {iH/tG'� '�Fu �i <G <br /> Qq, L e� /imG G , <br /> Signafurezr,Mu.�� '�. ��a.�/h+.> Date /o - S • a o � 5' � <br /> � <br /> i <br /> � <br /> I <br />