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Backwater Prevention Device Rebate Program <br /> Rebate Appli r .tOfl Form <br /> Property Owner Name: n1 (1,1-6LAA.,,m <br /> Installation Address: CC)(Z. 0( Ali <br /> State: ("Lei* qekri t) <br /> Mailing Address(if&km* 5. b 60-1., ,t/ 734/&: <br /> City: 17-4yez-r State: itein-- Zp: 9210-3 <br /> EmaO:jflk 0-keen/VA 09/141611 ti 114ne:(1471--- ? / 7T1 Z-33 <br /> Total Cost to Install Device(from contractor in $ S1cP <br /> Please verify the following: <br /> NI4am the owner of the property where the backwater prevention device was installed. <br /> 53/worked with the contractor to determine the location for the backwater prevention device and <br /> understand that the decision regarding the location of the device was mine. <br /> IAAly contractor instructed me how to access,inspect,and maintain the device. <br /> al/I-understand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in gond working order, unless it is installed in the city right-of-way. <br /> ri"441 sell my property,I will make potential buyers aware or the backwater prevention device and <br /> the need to inse;e, and maintain it on a regular basis. <br /> [Keram enclosing ell of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> Ej The contractor identified downspouts or other drainage Hines that were connected to my sewer <br /> line(between my house and the installed device)and removed,or rerouted them. <br /> BY‘my knowledge,my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> El There are downspouts or other drainage lines connected to my sewer line(between my house <br /> and the installed device). I undmtand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> Signature 4/. J7 -(,21- Date Vvr <br />