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, <br /> i <br /> 1 <br /> 1 <br /> biONP" Backwater Prevention Device Rebate Program <br /> 400,714- <br /> vaill Rebate Application Form <br /> Property Owner Name: ,,,,O ..0 \-, CI-0 1 <br /> Installation Address; 1. 6 <br /> e)cyyvy /kw <br /> City: ..,-Fvevito State: (41‘14— Zip: C1.11/0 8 <br /> Mailing Address(if different): <br /> City: State:. Zig..., <br /> Email: ' .• Mom join ttclinOrkinititloi Phone:4.4,, fl--olz3 <br /> — 2_C <br /> Total Cost to Install Device( in contractor invoice):$ <br /> 1 <br /> 1 <br /> I <br /> Please verify the following: <br /> ff"I's:am the owner of the property where the backwater prevention device was installed. <br /> I 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 /> IVly contractor instructed me how to access,inspect, and maintain the device. <br /> Vie--. <br /> rnderstand that I am responsible for maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> 11141 sell my property, I will Make potential buyers aware of the backwater prevention device and i <br /> • the ad d to inspect and maintain,it on a regular basis.the yellow Rebate Submittal Checklist)..f......"ee <br /> elect from the following: <br /> 0 The contractor identified downspouts or other drainage llines that were connected to my sewer <br /> line(between my house and the installed device)and removed,or rerouted them. <br /> Orny knowledge,my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> 0 There are downspouts or other drainage lines connected to my sewer line(between my house I <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> a <br /> Signatu :- Dte 2-C lb— <br /> 11 CA)31'" <br />