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<br /> ' � ' - , . Ba�,kwater Prevention Device Reb,ate Program:�; ;
<br /> Rebate Application,Fo�m ' � - . �
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<br /> Property Owner Name •'
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<br /> lnstal!ab�m Address � �� _ ✓ � ' �
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<br /> City: `U'�-�' /. SCate. _Zip __� G_-C� _ ;
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<br /> ��� � ' .� ' Pllailing Address (rf drf(erent) --•�� � � 5 _ ,Q �G(f-Pi ' '
<br /> City . ��� Slate :,' `'-7_ip � ` ` �
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<br /> � �, Total Cosl Io IRstall Devfce,(from coritractoririvoice) S '�
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<br /> ` Please�yerify the;followmg•:' - !
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<br /> � � -,. � I�am'the ��merof the properiy where�f'ie backPrater preventior device was i�stalled ' � `'� �
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<br /> ;� Gl I worked +ilh the contracEcr to detenr�ne theiccatlon for the bacKwater prevenlion device and ,
<br /> , �� understand that the decisi�n regarc+lpg the IocatioGi of the'devu.e v�as:mine i
<br /> �� ,, � My conlractor in t �ted ma ho��fo access inspack and mamtain the,dP�ice : i
<br /> �s , ' . (� I un�e�stand lFiat I am re<pan ib'e(o� maintaming ihc�ackwater prevention device and keepmg r
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<br /> � ;d m good�vorlcing crdf�r;uniess d is in�taUed m;the _ily�ight of-way: ; , I
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<br /> ;., �. If I sell my pronerty I v�i;l`make poteiitial 6uyers�.aware oCthe backWaFer prevention device and _.' _ ;
<br /> Ihe.;need to.inspect and:ii�aintain it on a,reyular batits � '
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<br /> ! � . �I ani,e� �losinq,all ol the nec��sary pap�rv�ork (use the yello�LRebate Su`mittaLChecklist). ., i
<br /> 7 • Select from thc Tollowmg _ �
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<br /> ;� � `.� [J l hc;conUactor.id�nhfied c1,br+rspoiitsor other dramage:llines �hat wer�con�ected to rny sewer� . �
<br /> <<� : Ilne (betweemmy h�u c�'?nd tre installed device) �nd removed, or,reroided tfizm , •
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<br /> 1 `+� � � Tp�my hnowfztlge my proi �rty has no downspouts or otlier tirainage�cenhecGed to my sewer line ;
<br /> ' � (tietween my hduse and;tli� mstallc��f�wce) -; 4
<br /> Thcre are dovii�s outs ofbther�rain- 4 line�connecten tn m sewer line befween in house ' �
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<br /> �. � '�' ''and lhe installed device).`,I;u�derstand ltiat leaying thcsr;�onnections creates a risk of flooding ;
<br /> ,' •''� . ' and I accepFth'at risk, •: ; , i
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<br /> Signatur _��i Date '�
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