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�Backwater Prevention Device Rebate Prograr� <br />� Rebate Application Form <br />,��y� <br />PropertyOwnarName� '' ^��4i���vl�le`� "c�� � <br />Inslallation Address� ��2 �� �� �� ���'�l S G/ <br />City: ��''lh'`�• �l�/ _ State: ����`" I Zip: ��G• ll� __ <br />Mading Address (il di1/erentJ: �T I! S�� __ /�(Z"e J� _ <br />c�ry: .SItC� lt.'lwt,-S � _ Stale: G��"L z�P: 7 YZ `id— — <br />E,rall � � c.n � ��l�r,%�-i �, L1n^'� Phone (�/CS `�7.i� Cv�3.4i <br />Total Cost to Instalf Device (I�om contractor invoice): S�o �� •�� <br />Pleasc verify the (ollowing: <br />�am Ihe owner of Ihe property �vhere the backwater prevention devica was instailed: <br />�worketl �vi�h Ihe coNraclor to determine the location for ihe backwater prevenlion device antl <br />understand ihat the decision regarding the Icr.alion of Ihe device was mine. <br />�My conVactor insirucled me ho�r to access, inspect, and maintam the device. <br />� understand that I am responsible fnr maintalning,the backwater prevenlion device and keeping <br />it m good working order, unir.ss it is inslalled in the ciry right-ol-way. <br />,8 If I sell my property, I will.make potenlial buyers aware of Iho 6ackwater prevention dovico and <br />the need to inspect antl mainlain it on a regular basis. <br />�� I am.enclosing all of Ihe necessary papenvork (use Ihe yellow Rebate SubmiltaPChecklist). <br />Select from the following: <br />,.Q �The conVar.lor identified do�vnspouts or other drainage Ilines Ihat were connected !o my sewer <br />line (between my house and Ihe inslalled device) and removed, or rerouled Ihem. <br />,['�To my kno�vledc�e, my propehy har no downspuuts or other tlrainage connecled to my sewer line <br />(belween my house ann Ihe �nstalled devlce). <br />.� ] There are do�vnspouts or uther.drainaye Iines connecled�lo my sewer lina (be�veen my house <br />and the insla�loA dewce). I undersland ihat leaving Ihese conneclions creates a risk of (loodmg <br />and I ar,copl lhal nsk. <br />i� f <br />/ /' <br />Signature r / ��'��-'I ' /�Oate , �% � .� <br />% <br />