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C�5/O1/:�15 13:23 4?546?5176 STD PnGE D3ICn <br />� Backwater Prevention Devic:e Rebate Progr2m <br />Rebate Application Form <br />t \ <br />� Property Owner Name JI�V r tJ b�--t—a-E '`� �l"i'�{ j�—( <br />tnslallal�onAddress: ���Z V'rl:����- /i'tv<— <br />� �iry: �iT1 --- Slate. � � . Z�R .. . — <br />MoiLng Add2ss (i/Jilf�re�rt). I�C\ _��+)C l? i r� � _ <br />City� =�4 V� Stale: �-� Zip: `1'�c ) l.� , <br />Emaii `� i��Ca �'�+��1�.�r� Phone (��j 44S J��� <br />Tot�� Co,t to Inslall Devicc (from conVBctor rrvolCe). $ <br />Pleaso verity the lollowing: <br />�am the cwner of thc property where Ihe backwaler prevent{on device was mstalled. <br />(y��l WDfkOtl wilh Ihr. eontraH. nr tn detcrmtne Ihe looa6on far tha hackwalnr provent�on devlcc and <br />under,(and thot Ihe decision reqa�ding the locabon ul U�e device was mine <br />�'? �td�y cnmrarinr InsttuCted me how lo accnse, Inopecl, �nd mointain lhc Oevice.. <br />�I understantl that 1 zm respons�ble br mamta:ning Ihe backwater preveNwn device and keeping <br />il in pnad wn�kinp order, anicss R it +nsla,lad m lho city nqhl of wcy. <br />;- If I scll my propeiry, i wtll make polentrai buyers a.varc of Ihc backwaler prevention tlewce and <br />IhP nPM In insped and mpinlain M1 on a roguUr EJLi�. <br />/� <br />(� I am enclosin� all of the netessary paperv+crk (use Ihe yellaw Rebate Submill7l Checkl��sq. <br />3eloct from Ihe lolfowing: <br />[] Tno eonlmc�or lden65eJ downspoWs or olhe� Jiainage Nnes !�at were COMCCIca lo my sev+er <br />line (bc�vicen my housc and l�e Ins1a11Cd dev¢e) qnd removed, ot retouled �hem <br />/ <br />D�To my Anowladge, my pronr.rty has no tlowuayuulo or olher Uramaye connectea ro my sewer Ime <br />(b0(1YCBf1 my h0U5e 80A �he In512qCtl tlPYit!?). <br />rj There a; UownspoWs or otner tlra�nage tlnes connected lu my sevier hne (belween my house <br />and the mstahed �ewce), I unde ,land thal Iraving Ihese connedwns r.reales a �isK of flooding <br />and I accept Iha( risk. . <br />�-,. <br />Sipnnfure --��� �7t � � ��'J DeIOT � f J� <br />