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r---,-- — <br /> �,�/� Backwater Prevention Device Rebate Program <br /> �'��,,,, Rebate Application Form <br /> w>--- <br /> Property Owner Name:��N� /��u� <br /> Installation Address: �J�p �•Qh-�� �J � _ <br /> City AJ.��----. ---State: �'Y Zip:��� <br /> Ma�ling Address(if diflerent): _ _ _ __ <br /> Cily:__ _ Slate: Zlp:— — <br /> Email: _Phone: di�p2�✓� �a�� <br /> Total Cost to Install Device (from confraclor invoice): $ �.%� - � -- <br /> Please veri(y the following: <br /> �] I am the ownor of the property where lhe backwater prevention device was installed. <br /> (� I worked with the contraclo•to delermme the location for the backwater prevention device and <br /> understand that ihe decision rrqarding lhe bcation of Ihe device was mine. <br /> �My conlraclor instructed me how to access, inspect, and maiMain the device. <br /> [� I understanA Ihat I am responsi6le for maintaining the backwater prevention device and'keeping <br /> it in good working order, uNess it Is installed in Ihe city right-obway. <br /> � �f I(I sell my proporty, I wtll make potential buyers aware of Ihe backwater prevention device and <br /> � the need to inspect and maintain it on a regular basis <br /> I am rnclosing all ol the necessary paperwork (us� Ihe yellow Rehate Submittal Checklisl) <br /> Select Irom the following: <br /> ❑ The conlraclor idenlihed downspouls or olher drainage Ilines Ihal wero connecled fo my snwer <br /> line (betwecn my hause and the inslalled dovice)and removed, or rerouted them. <br /> �To my knowledgc, my properly has no downspouts or olher drainege r.onnectod to my sewer line <br /> (between my house and the installed devir,e) <br /> ❑ There are downspouts or olher drainage lines connected to my sewer line(btslween my house <br /> and the fnstalled device). I understand Ihat Ieaving ihese connr.clions creates a risk of Oooding <br /> and I ar.cept that risk. <br /> /1�____�� Date �' 3—/ � <br /> Signafurc_f� _—_ <br />