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_.. - -- -- ---__ . . - -- - - — - _ _ . — <br />� .,- <br />�Backwater Prevention Device Rebate Program <br />d Rebate Application Form <br />Property �nmer Name: �DDVr� V� 1 � L•�JQCP_+lc� <br />Installalion Address: <br />�� � � 1%i N <br />� � �.�{ U <br />City: �[�tlLvl ' State: �/✓1� Zip: °�(iZC' � <br />Mailing Address (i(dilferenQ: <br />Cily: _ State: _ Zip: <br />[mail: hIL iJ�E'flG�n�(A,(,J_LOlM� Phone: (yZf��� ���_� �._ <br />Tolal Cost to Inslall Device (trom confrac(orinvoiceJ: 5 ��5�•� __ <br />Please verify the following: <br />[3�1 am the owner of the properiy where the bar.kwater prevention devlce was inslalled. <br />�i�—Yworked wilh the contraclor to delermine Ihe localion for the backwaler prevention device and <br />understand Ihat the decision regarding the localion o( lhe device was mine. <br />�`FAy contractor inslructed me how lo access, inspect, anA�maintain lhe device. <br />� I understand lhat i am responsible for mainlaining the barkwater prevenlion device and keeping <br />d ir yood working order, unluss d is insfalled in lhe city right-^f-way. <br />[!' (f I se�l my property, I will make potr,ntial buyers a�vare of Ihe backwaler preven�ion device and <br />fhe need lo inspect and mainlain il on a reyular basis. <br />���f am enclosirg all ot t„c aecessary paperwork (use the yellow Rebate Submitlal Cher_klisl). <br />Select from the (ollowing: <br />r�Tf�e r,oniractor identified downspouts or othr.r draina�e Ilines Ihal werr, conner:teri to my sew���r <br />��t(� linc (belween my house and lh�� inslalled device) and removed, or rerouled Ihem. <br />[.�' To my Y.nowledgc, my propr:rty has no dovmspouls or other drainane conner,ted lo my sewer line <br />(behveen my house and Ihe installed device). <br />(J There aie downspouls or other drainaye lines wnnecled lo my sewer line (belween my house <br />and lhe installed device). I undersland thal leaviny these connec�ions creales a risk of Iloodiny <br />and I accepl lhat risk <br />t / �1,, ��7 <br />Signature__,i�'� � ' ��'i^ Date _.� r � � _ <br />�r ✓ A-�9Yi'�;iYut_: rCxc-G!_'. �G� <br />