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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> E6.7.7.. <br /> El, <br /> , (----11E. 11-'1 it., <br /> Property Owner Name: <br /> -) <br /> ,g14,LH--),_ 7.3c) ? <br /> Installation Address: <- <br /> ,,,cty.,,t,,,,,,.,41E LIty2.... .;_i tit_ <br /> t/E-ria--1C- <br /> City: State: r . <br /> Zip: <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> ,,-,...,,,- ,7;_q_49... .....R <br /> Total Cost to Install Device (from contractor invoice): $ op t4 3/,..... <br /> .._ <br /> 6‘1.Lw <br /> Please verify the following: <br /> ' k'fil am the owner of the property where the backwater prevention device was installed. <br /> [ 1 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. <br /> FMy contractor instructed me how to access, inspect, and maintain the device. <br /> I understand that I am responsible for maintaining the backwater prevention device and keeping <br /> i <br /> ( it in good working order, unless t is installed in the city right-of-way. <br /> ,,,, <br /> * <br /> .., i rp If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> ''' 'i'ii<i;i.l.diii i' the need to inspect and maintain it on a regular <br /> arbasis. <br /> (0. I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> t "- (--- <br /> , ...„.- <br /> Select from the following: <br /> i,;1/411 The contractor identified downspouts or other drainage !lines that were connected to my sewer <br /> line (between my house and the installed device)and removed, or rerouted them. <br /> To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> .... . , <br /> .... ,, <br /> There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> 11 ,ii', <br /> iiiii ,,,;":,i,k'i,iii'ili;', 7 <br /> -4,:ifi,4,t',--.iiii4q,..2t71;,, <br /> :*141-,(6.4-I/.: •..: ,''' i <br /> 4";,4,t,:7,41i4NO:4R4kti Date s tagfab(5-- <br /> .-. <br /> ','"•,,,r.', <br /> ':Iii,'''I.::::',1. ?";ff.,,14„e7:7;,•:;!:,11A!?••••78!z:.,,,, , ,. <br /> 1-;itikit4e''.:Y;'64'±::;!:':::'::::•"''''::::'ic .'" ''- •4 ., ". :.,-•44::4•"4$ ::$.,::,:iii*';P*X .iiiif4ftititilia::`-:,:iil,v, <br /> •.:"=*4'l""""-".4 Y ,,,,.„„4,4 4.x4-i4...,..e.,,,, ,'.',';,04 mn.,,,,.›.:Irm.,,, ,, „,,,,,,,..,..,4..,i,,t , ,, ,, .-: ,„ .„.„. ,,,„,„ ;,: •)„,,,,,.(4,,,ts:.,,,, ,;p, '0,4' ("Vakt.1 '';':',.z.r4;.V:3%-4,151tkr- ---..§,;74,,-;";*1-,:;',- <br /> t. z,..•",z ''€::::,:..;j::."="4:1Firi"Tt;•?Ilt-24,a g<.',4;44kRitalif.:"::'iizte:?:;;IiP%44,34'''..;ii'ai'.'•° ,;iiitt;C4c.::;:.'tfie::2''',.''':':;‘,,,ditt,'!2:, "..:!"illti%:-i,:-.:".,..;...'•".;:k.'‘,'C;, 'Airt:ri!'," --All:4'1)14',.' 4*,'''.,,.." 11,",tlets,,,.'',''ea <br /> i'i,2,,,..,..• ;:,,,••;,,0.4.-o's,',1,,..;.r..",-,.:i'''.;t:-s°.,';.i.,3',(,:•;i1,41,320°,%4Wer''4'''iii431A,61;'SI'''''1.4';'!";›,,,t '''';'i.,°':'1W';"'''..s,;;.,''-i•",',;('''''.`:,e?,,,a.v5T,,i1.5,2 ;11,:,;,,,,A.4.,...,,,,t;e:::=,,,,,:,-,:tif,a„-,..:,,,,„,:,:,,,,,,..:4;,,' v- <br /> i'ltA,:,:*:,4,,,;,,,,= :•;«-:1,V,',,i4.„3-1.....aillke:„..!:,:ity,,',0:,,,afivt: ','..i.i,,:,,,Ai7:;1:1"!",,,,, .h,,,t;,,i,,,::-',,t,,,Te;',47-)".1%1°0•• . 4,..,,,X, `te,,,L.',,,A,i:'''$r..,,*.„, ,,,,,,- , 7,- z• , - ^ , <br /> litt •,!')**3,=Vt\A"•6,5--i'Z-.7..: qai*a'-",'1,717--,:::,-1-,‘ ,' ,, , <br />