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<br /> Backwater Prevention Deice Rebate Program:
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<br /> Rebate A.pplicat1oln Form
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<br /> Property Owner.Name. _ l i1�{Gt - e 1�l�
<br /> Installation Address: 1 _Cr�1 UCS C{
<br /> City �' State: U.f Zip: � Zv
<br /> •Mailing•Address(if different): i U ClohQ m 15 h ,k Ue,
<br /> City: l-v•�?es State: � Zip � .-
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<br /> Email: .. e f_t, I °1:-
<br /> C,1-.2.-esu,.,Cc�Yv� Phone: (1I?S)a � /(o/, • i
<br /> ;Total Cos#to Install bevice(from contractor invoice) $..... o 10�'
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<br /> Plea•s•e• verify the following
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<br /> am the• owner of the roe where the backwater revention device was installed. I
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<br /> [ l worked with the contractor to determine the location for the backwater prevention device and
<br /> understand that the•decision regarding the location of the device"was mine, ,.. i......• i
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<br /> ....":
<br /> [, My contractor instructed me how to access, inspect,and maintain the device.
<br /> [azi- understand that I am responsible for maintaining the backwater prevention device and keeping
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<br /> it in good working order, unless•itis installed in the city right-of-way,
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<br /> If I sell my property,:l will make poten•tial buyers•aware of the backwater prevention device and
<br /> the need to inspect and maintain it on a'regular basis.
<br /> • ❑•. lam enclosing al!of the necessary paperwork(use the yellow Rebate Submittal Checklist). a
<br /> Select from the following:
<br /> 0 The contrac' ide• ntified downspouts or other drainage Ilines that were connected:to my sewer
<br /> line(betwe•en•my house and the installed device)a•ndremoved,or ferouted them: r
<br /> Tom knowled e,m roe has no downs outs or other drains a connected tom sewer Line I
<br /> Y 9 . . YP P �Y P. g Y
<br /> (between my house and the installed device)
<br /> There are downs outs or•other drains a tines connected tom sewer line. between m house
<br /> ED P g . Y ( Y
<br /> and the installed device). 1 understand that leaven these•connections creates a risk offlooding ii.
<br /> and l:a(cept that risk
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<br /> signature � >f(/VI d Date �' ' 2:0(.S
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