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,t <br />i;J: <br />_.,�y <br />.`'', • ;,: <br />.,.': .,.; ; <br />�: c,: � . <br />�•1�'I�� <br />Backwater Prevention Device Rebate Frogram <br />Rebate Application Form <br />Property Owner Name: `� �1 � ��� �� t/f�.�.\ nh <br />C.� �fUhl�1 <br />InstallationAddress:,��� � �f nn � <br />City: �\��� Slate:r.v_l�T�a �_,� <br />11�_z�P: ��ZOI <br />Mailing Address (iI dilferenf); <br />City: S�ate; <br />Zip: <br />Email: 5�%��1��p ��%�,/ � �n �� Fhonc: (-�L� �3�- �S'��) _ <br />-�� �21�. <br />Totai Cost to Install Device (from contncmrinvoico): $__ <br />Please verify tho following; <br />� I am tho owner o( the properiy where Ihe bacMvaler prevenlion device was installed. .�. •��`,' <br />� I worked wilh ihe contractor to determine lhe iocation lor lhe backwaler prevenlion device and <br />understand that Ihe decision regarding the locatlon ol the devite was mine. <br />� My contraclor instrucled me how lo access, inspect, and maintain Ihe devlco. �•� <br />'�] I undersland that I am responsi6ie for maintaining lhe back�valer prevenlion device anB kecping <br />�� it In good working order, unless it is installed in Ihe city righ�•of•way. '��' <br />Q,� I( I sell my property, I will makc polenlial buyers aware of Ihe backwaler prevenUon dovice and <br />�� lhe need to inspect nnd maintain it on a regular basis. <br />1F.1 I am enclosng all of the necessary papenvork (uso Ihe yellow Re6ale Submittal Checklist). <br />1-T <br />Select from thc following: <br />❑ The contractor ldenlified downspouls or olher dralnage Ilines Ihat wero connecled to my sewer <br />line (beN�ecn my house and Ihe installed devicc) and removed, or rerouled them. <br />❑ To my knowledge, my property has no downspouts or olher drainage connecled to my sewer line <br />(betwecn my houso and Ihe installed devlce). <br />nj There are downspouls or other drainage lines connecled lo my sewer lino (beM1veen my house <br />7� and the installed devicej. I understand thal leaving Ihese connec�ions ereates a �Isk of Ilooding <br />and I arrent Ihal dsk. <br />Datc "T � ��_ <br />