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- �i <br /> Backwate�• Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner,Name: ��" O�� _ <br /> Installatian Address• �/��1 � y�^� �'T `� <br /> City: �2�✓�� State:_W 1� _Zip: ��'i� I <br /> Mailing Address(fl dil/erent): <br /> City: State: Z�P� <br /> Emall:�;.�. �t�S�'� ��' ���—Phone: (L�� �I � '�-�`1 , <br /> Total Cosl to Install Device(from cenfractor involce): S "r�—�� <br /> Please verlfy the(ollowing: <br /> �i am the owner of the property where the backwater preventfon device was Installed. <br /> I worked with ihe conlractar to determina the location',ur ihe backwaler prevenllon device and <br /> understa�d that lhe decision regarding the Iocation of the device was mine. <br /> �Niy contractor Inslructed me hc�v to aca+ss,inspect, and maintafn the device. <br /> � Funderstand that Pam responsible for mainlaining the backwater prevention device and keeping <br /> it in good working ord�tr,unless it Is instelled in the city right-ot-way. <br /> � If I sell my propeAy, I wil�make potenlial buyers aware o1 the backwater preventlon device and <br /> the nsed to Inspect and malntafn It on a regular basls. <br /> I�I 'I am enclosing all o(the nocossary paperwork(use Ihe yeltow Rebate Submillal Checkllst). <br /> v� <br /> Select from the following: <br /> �The contractor ldentified downspouls or other drainage Ilines that wera connected ta my sewer <br /> rTne(belwet�n my house and the fnstalled device)and removed,or rerauted lhem. <br /> � To my knowledge, my properly has no downspouts or other drainage connec!ed to my sewer line <br /> (between my house and the Installed�device). <br /> � There ara downspouts r other drainege lines connected to my sewer�ine(beriveen my house <br /> end the Inslalled de I understand lhat leaving ihese connecUons�.�eates a risk ol Ilooding <br /> and I accept thel rf . <br /> Slgnature Date '�I L � <br />