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�,�}� Backwater Prevention Device Rebate Program <br /> ^�— Rebate Application Form <br /> M�C�'S/aeii <br /> \.� <br /> Property Uwner Name: _�,1{,�Cr.I.LT� ���irf�i ��� <br /> Installation Address: �IL/� R�–J�c2So� Ir3' `J� _ — <br /> City: r��1g� State:���_Zip: I�7o 1 _ <br /> Mailing Address(il dilferent): <br /> Cily: State� Zip',_-- <br /> F.mail'--- -- --- — -- Phone ( )— ---- - <br /> 2 G � <br /> 1 otal Cnst to Install Device (fmm r,ontracfor invoice)' $ �S� _ —_— <br /> Please verity the fotlowing: <br /> � I am the owner of the property where the backw:.:t•prevention devico was installed. <br /> �J I worked with the contractor to determine the location for Ihe backwaler prevention device and <br /> understand lhat Uie decision regardmg lhe localion of Ihe device was mine. <br /> �J My contraclor instructed me how to accesa, inspeU, and maintam the devicc. <br /> � I understand that I am responsible lor maintaining Ihe backwater prevention device and keepinc� <br /> it in good working order, unless it is inslalled in the city riyht-of-way. <br /> �J If I sell my property, I will make potential buyers aware o(Ihe backwaler provonliun device and <br /> the need lo inspect and m�intain it on a regular basis. <br /> � I am enr.lnsing all of the necessary papenvork(use the yellow Rebate Submittal Chocklist). <br /> Sclect from tho fallowing� <br /> n Thr, contrar,tor identified dnwnspnuls or othcr drainape Ilines lha� wnre connected to my sewer <br /> line(between my huuse and Ihe installed devico)and removr,d, or rernuted Ihem. <br /> � � To my knowled�e, my properly h;is no downspouts or other drnlnage conner.ted lo my sewer line <br /> (betwoen my house and thc installed dovice). <br /> �. fhere are dawnspouls or o�her drainage lines connec�ed lo my sewer line(belween my house <br /> and Ihe msl�lled dewce). I undersland lhal leaviny lhese connections creates a risk of Ilaodiny <br /> and I accepl that nsk. <br /> Slgnature��J /' Dafe ��1-� S� <br />