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' <br /> � <br /> BackwatewPveventlon Device Rebate Program <br /> R~~^~--- �- -o-or � FOrm <br /> �KD8~ -�� <br /> FProperty Owner Name:-V\O C <br /> Installattion Address. <br /> Mailing Address (if diffiferent): <br /> City: State: Zip-, <br /> Email: Phone: <br /> Total Cost to Install Device (frorn contractor invoice): $ 14 a "�S` <br /> -- <br /> please verity the following'. <br /> I am the owner of the property where the baclwater prevention device was installed. <br /> I worked with the contractor to determine the location for the backwater prevention device and <br /> ~+ <br /> understand that the decision regarding the location of the device was mine. <br /> My contractor instructed me how to access, inspect, and maintain the device. <br /> -r th backwater pnavondondevice and keeping <br /> | undomtend �ha�| amnesponsiU\�fnrmaintaining e <br /> itiogood working order, unless itisinstalled inthe city hght-of+may. <br /> [� <br /> if I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> �= <br /> the need toinspect and maintain itonuregular basis. <br /> I arn enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklis!). <br /> 7- <br /> Select imomm tile following: <br /> Fl <br /> The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> line (between my house and the installed device) and removed, or rerouted them. <br /> ToDoybnom/|edge. noyprope� n? <br /> yhmnnodmmna�outooroUnerdroinaQeunnnoct��foyoeVverUno <br /> r- house(between my oua '' <br /> There are downspouts or other drainage lines connected to my sewer line (between my <br /> hereareduvvnspoutauroiherdrainago|ine000nneoiedtomyaewer|ine (botmaenn/y house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and | accept that risk. <br /> - <br /> Date <br /> ` <br /> . � <br />