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�,�}� Backwater Prevention Device Rebate Program <br /> �M�,�,., Rebate Application Form <br /> � _�-• - <br /> PropeityOvmerName, To�lo�_��� S _ <br /> Inslalla6onAddress. Z�I �C I>G��-G� l'`��� <br /> Gty ��v t State: �L _Zi �v I <br /> P - ��-- ----- <br /> Wlailing Address(il dillerentJ _______ ___ <br /> Ci;y: State: _______ 1ip <br /> Email ____ __ _ __ Phone, ( ) _ <br /> Total Cost to Install Device Urom confractonnvoicef $ _ 2�'j_oU , (� � _ <br /> Please veriFy the tollowing: <br /> � I am the owner ol the property where the backwater prevenhon device was inslalled. <br /> � I worked with the contraclor ro Aetermine the location for the backwater prevention device and <br /> understand that Ihe dec�sion regarding Ihe location of the device was mine. <br /> �] Iuly conlractor inslructed me how to access, inspect, and maintain lhe device. <br /> �j I understand that I am responsible for maintaining the backwaler prevenhon device and keFping <br /> il m �ood ivorking order, unless it is installed m Ihe city riyht-of-way. <br /> �} If I sell my property, I wdl make potential buycts aware of the backwater prevention device and <br /> �he need to inspect and mamtain it on a regular basis <br /> � I am enclos�ng all ol the necessary papenr�ork (use the yellov� Rebale Sub�nittal Checkhsl) <br /> Select from the (ollowing: <br /> �CJ ihe contraclor identihed downspouts or olher drainage Ilines thal were connecled to my sewer <br /> line (between my house and the installed device)and iemoved or rerouled lhr.m <br /> �J To my knowiedge, my property has no downspouls or other drainage connecled lo my sewer line <br /> (between my house and Ihe installed device) <br /> � There are downspouts or other drainage lines conn�cted to my sewer hne (behveen my house <br /> and the mstalled Aevir.e) I undersland that leaving these wnnections creates a risk of floodiny <br /> and I ar,cepl that risk <br /> �J .�. <br /> Signatur¢ `� , ��_� _Date "/ ! /� <br />