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1 <br /> i <br /> i <br /> f <br /> 1 <br /> el I II liMma <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: D a VA 6''''II fe.ktos,-A frt , <br /> Installation Address , <br /> -=t. iF____ ___ Zip: <br /> City: �-�� State: i <br /> Mailing Address (if different): <br /> City: <br /> State: Zip: <br /> Phone: ( ) E <br /> Email: <br /> Total Cost to Install Device(from contractor invoice): $ <br /> 3 <br /> Please verify the following: 1 <br /> F-I am the owner of the property where the backwater prevention device was installed. <br /> 1.1V1 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 /> '' y <br /> M contractor instructed me how to access, inspect, and maintain the device. <br /> tIlE I understand that I am responsible for maintaining the backwater prevention device and keeping i <br /> it in good working order, unless it is installed in the city right-of-way. I <br /> If I sell my property, I will make potential buyers aware of the backwater prevention device and 1 <br /> the need to inspect and maintain it on a regular basis. <br /> f <br /> I am enclosing all of the necessary paperwork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> The contractor identified downspouts or other drainage linnes oved at were <br /> them. to my sewer 4 <br /> line(between my house and the installed device)and e <br /> . property has no downspouts or other drainage connected to my sewer line <br /> (between my <br /> R, To knowledge,house and the installed device). <br /> or <br /> rainage lines connected to my sewer line <br /> and the re installed downspouts ). other under tand that leaving these connections creates a(between <br /> sk of flooding {. <br /> and device) <br /> and I accept that risk. <br /> t <br /> 7 <br /> �"'�� " � ,tea <br /> s <br /> Date c ' i 1 <br /> Signature u . i <br /> ;t <br /> , <br /> 1 <br /> 1 <br /> i <br /> a <br /> i <br /> 1 <br />