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`� <br />Backwater Prevention Device Rebate Pragram <br />Rebate Application Form <br />Property Ovmer Name: ,1135<0 � aMd S�It��h 0.�� u b <br />inslallation Address: 2 6 �� R���C2d-e�id �`/✓(^'"Q- _ <br />Ci�y: ve re f{' . _` Slate: W� z�P:_ 98�.n� _� <br />Mailing Address (if different): �� g3� L( a�/'C ✓� ./ �� <br />City%�+�C� �oS �' �ar k Slate: W� Zip: �0 � J` S <br />EmaiL c. aVG�qyvlal�• GD✓✓� Phone:(ub� `�l7-95�Z <br />Total Cost to Instali Device (lrom contracfor invoice): S��6 - 3/ <br />Please verify the following: <br />o�. � p�.d ��r� ��- <br />r•�.,�.. �ts4r3 <br />z�q�•sr <br />P^�� yP^+ <br />(�I a�n the ovmer o( the property where lhe ba�kwaler prevention device was installed. �c,,.,. �4,..rew <br />[.�}�I vrorked tivith the contractor lo determine the location for the backroater prevention device and _ k�`i l�S <br />understand that the decision regarding the location of the device was mine. <br />[�My contractor insiructed me hove to access, inspecl, and maintain ttie device. <br />�I understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good tivorking order, unless it is inslalled in the city right•of-�vay. <br />[v� If I sell my property, I will make potential buyers aware of the backv�ater prevention device and <br />the need to inspect and mainlain it on a regular basis. <br />� am enclosing all oi the necessary papenvork (use the yellow Rebate SubmiUal Checklist). <br />Select from the fo!lowing: <br />❑ The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br />Iine (behveen my house and the installed device) and removed, or rerouted them. <br />[� To my knoveledge, my property has no downspouts or other drainage connected to my sewer line <br />(behveen my house and lhe installed device). <br />(—J There are downspouts or other drainage lines connecled to my sewer line (between my house <br />and lhe installed devicej. I understand that leaving these connections creates a risk of flooding <br />and I accepl that risk. <br />Signatur �<i�G����a ��i�- _ Date ��— �i —/5 <br />