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i <br /> i <br /> i <br /> �,�}� Backwater Prevention Device Rebate Program � <br /> �'��— Rebate Application Form ; <br /> w��,rr„ <br /> � ; <br /> , ��,�y , — � <br /> Propr.rty Owner Name �ld 1� � "' '�(i{.`'��'l�1/I rt.Q ��(�� '�-�� � <br /> iInslallation Address:�J �J �P�� Q/ ��- 1 <br /> City:�Y.l_t State:_�._7_ip: � O�� i <br /> Mailing Address (ildilierenQ: � i <br /> � <br /> Cit �a��e7 Zi � <br /> y'— —n— P t I <br /> Email:��l i�1'P 1�1 i�l��til'k,—<4 t'['� L3vlG1,lJ'� �ne: (y�.t,"T ��� ' �J�% ` <br /> Tolal Cosl lo Install Device (lrom contractorinvoice): S ���J�'�� _ � <br /> � -- - � <br /> � <br /> Please verify the following: � <br /> � I am the owner o(Ihe property where the t�ackwater prevention oevice was installed. ! <br /> f�I worked wilh Ihe conlrar�r lo delermine the location for the backwaler prevention device and j <br /> f undcrstand lhal thc decisi�n regarding Ihe location of thc device was mine. <br /> �My contractor insirucled me how lo access, inspect, and maintain the device. ': <br /> i <br /> ��I understand ihat I am responsible tor maintaining Ihe backwaler preven�ion device and keeping j <br /> il in good v✓orkin� order, unless il is installed in ihe city right-of-way. + <br /> �r If I sell my property, I will make potential buyers a�vare o!the backwater prevenlion device and l <br /> the need to insper.i and mainlain il on a regular basis. 1 <br /> �'] I am enr.losing all o(Ihe necessary paperwork p�se the yellow Rebale Submittal Checklisq. � <br /> 1 <br /> Selocl trom the following: � <br /> X J The contradnr identified dov+nspouts or other drainage Ilines that were conner.led (o my smver 1 <br /> � Ime (belween my house and U�c installed device) and removed, or rerouted ihem. <br /> (- � To my knowledge, my property has no downspouls or other drainage connecleA to my sewer line � <br /> (behvr.cn my house and Ihe installetl devicc). i <br /> ❑ There are downspuuts or olher dramage lines connected to my sewer iine (bclween my house � <br /> and the inslalled device). i understand Ihal Ieaving these conner.lions creales a risk of flooding � <br /> and I accepl lhal nsk. � <br /> i <br /> � <br /> /� � i � ( - -�� i <br /> Signature_�l�L'�fi�/,i h �� Ll/C�1 Dafe_ ; <br /> i <br /> I <br /> � <br />