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Backwater Preve��fior� Devicc Rel�afe Progr�rl� <br /> E„ Rebatc ApE:�iication ForrY� <br /> � <br /> __.—__.. _-- __ <br /> __ � g <br /> � � � <br /> Property Qwner Name:__�!������ �{�'��i�---�' <br /> Installation Address: ,��=��� ��t�'��;`���-� �'�'a� <br /> . ,��" . <br /> � � �� �� �' -� � <br /> City ��_�tC�Ke```! r ____,.. ;�I�if�� �;��''��" IiE�: �� �`; , <br /> Mailing Address (ifdifferei�t): <br /> City. -------- - - St��t�r. Zip: <br /> Email:_ ____ f'It��nc�: (���`� �'����",�-��"�,� <br /> Tofaf C�st io Install Device ((rorr� cc7i�U�rlr:trari>>voir.r,): � ����� ` T <br /> k <br /> Please verify the following: <br /> r <br /> [�! arrt the owner of the property wher� th�: l�ac:kw�lc:r prev�nti�n dc�vice wris ins(��Ilc�ci. <br /> [� I worked with the contractar�to determin��the�loc�;�tion for the t�ackwE�kt��r��E�rr:vE�niir��� �ic�ai��t�, z�nci <br /> understand that fhe deeision regardir�g llxa I������tiEan of the d�vic� was �itiiic. <br /> ['� My contractor instructed me how to ar.cr,ss, inspecl, �ii�d m,aint<ain tha dr.via: <br /> [�I understand that I am respor�sibic fc�i ni<�ii�ir3ininy fhe l.r,�ckw�tc:r ��rcv��nli���� �i��vir.,: ;,��,i k������ing <br /> it in good working order, unless it is instllll['d II1 lll�city right-of-way. <br /> [�lf( sell my property, I will make Frotentir�! buy��rs aware��f th� bar,kw.3lr.r preva��fi�ni iicv�cE��;:�nd <br /> the r�eed to inspect�and maintain il ori �3 rec�ular�b��sis. <br /> [�]'I am er�closing all of the necessary E>a�erwc�rk (�rse lhc; ycllow Rehate Sul�n�iit;�l t;hr��:klist), <br /> Select frorn the following: <br /> �_.) The contraclor idenkified downsp<�uls ��r o(I�i�;r�Irrain�.�ye Ilinr;s 11����1 wtrrr. �:��i�r7��cl�r�1 f�� n�y r;�>�,vur <br /> iir�e (t��(ween my house and the instalfcd d��vir;��:},�r�d rerrtoved, or r�:r��u(ec� (I�cia�. <br /> [�j To ��1y know(�dge, my properiy�i�as�no c1��wt��;�rauts t�r oflte r dr�3in����<��r�c:�>tu��>cfeti i�� ni� ;���wrtr lii��� <br /> (t�etwe�.n rny house anci the�it�st�lleci dt�vicr.}, � <br /> � � ��lit��rcr,�tc �i��wnspouts or otf�E�r tii�3in��i��� lin��:; ct,n��e�;ltr�i f�� niy ;;nwir� liii�� (l,�,iwE���ri niy lirru:;<< <br /> ��nti II��� ii�slnlled device). 1 undersla[��� ihr�t Ic���v�n�� lh�-:s�� �;tmn{:ctit�i�;� crr�,il��:; ,a ri�,l, nl Ilu���ln!�� ' <br /> r�ncl I �ic�;i�pi (I�at ris�. � <br /> e �. <br /> Signctlrir�� � � DatP �� � ���j �✓ <br /> �� _. �� — �� ------. . _ <br /> � <br /> � <br />