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Backwater Prevention Device Rebate Program <br /> _ Rebate Application Form <br /> Property Owner Name: Fto rd feirri Eltrgs1 t `U rd o ) <br /> Installation Address: I 4:00;), tYl' bO r I <br /> 1 ; <br /> City: C�:� � �� State: l>`°�� Zip: 9 :D.-o 1 "` (7 30 <br /> Mailing Address (if different): IC) Co (0 .;t sr i `e t --) <br /> City:GC v Y"tCI lSlethc State kii,,Y4 Zip: G S 28 2 <br /> Email: \f-tOV C)c 1-00(ec k IEeccann Phone z 7O?& <br /> Total Cost to Install Device(from contractor invoice): $ 1 D a-' <br /> Please verify the following: <br /> la I am the owner of the property where the backwater prevention device was installed. <br /> Az 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 /> XMy contractor instructed me how to access, inspect, and maintain the device. <br /> rin I understand 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 /> RI If I sell my property, I will make potential buyers aware of the backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> caI 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 Mines that were connected to my sewer <br /> line(between my house and the installed device)and removed, or rerouted them. <br /> To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br /> and the installed device). I understand that leaving these connections creates a risk of flooding <br /> and I accept that risk. <br /> e <br /> Signature , Date q_ q_1,5 <br />