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�. _� �`1 <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name:�VJ�Y � -E' > > Y � `� � ������ <br /> Installation Address: I LD �� W'�� T��`�-�v� <br /> City:_���t�1�" S;ate: Vv� Zip: `I D �—Q ( <br /> Mailing Address(if dilferent): � 1� ���� �-1 " L- V v <br /> Cily: ���"�� State: V�-.�'-"S Zip: � U /��� <br /> Email:(,L�QQ,_��/jrGl_�'1 V11A1'l/� ���� Phone:�� J�� 2� 0 <br /> � a"D <br /> Total Cost to Install Device (Irom contractor invoice): $�' �J � . <br /> Please verify the following: <br /> �I am the owner of the property where the backwaler prevenlion device was inslalled. <br /> �I�vorked wilh the contractor to determine the location for lhe backwaler prevenlion device and <br /> undersiand that lhe decision regarding the location of the device was mine. <br /> ��4y contractor inslructed me how to access, inspect, and maintain the device. <br /> � ' undersland that I am responsible for maintaining the backwater prevention de��ice and keeping <br /> � it in yood workiny oider, unless it is installed in lhe cily right•of•way. <br /> � II I sell my property, i will make potential buyers aware of the backwater prevention dovlce and <br /> the need to inspect and maintain it on a regular basis. <br /> �I am enclosing all of Ihe necessary paperwork (use the yellow Rebale Submiltel Checklist). <br /> Select from the iollowing: <br /> � The contractor idenli(ied downspouls or olher drainage Ilines Ihat were connecled lo my sewer <br /> lino (between my house and the instailed device)and removr.d, or rerouled �hem. <br /> �j' To my knowledge, my p�operty has no downspouts or other drainage conneeled lo my sewer line <br /> � � (between my hause and the installed device). <br /> 'h4 There are downspouls or olher drainego lines cannocled lo nry sc�wer line (belw�ten my house <br /> l�ond Ihe inslalled device). I undersland that Ieaving these comiections creates a risk o(Iloodinq <br /> and I acccpt Rial risk. <br /> Signature � ' Date�� L✓� <br />