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/��� Backwater Preventfon Device Rebate Program <br /> � Rebate Application Form <br /> PropeAy Owi��r Namc �Z���j� _ <br /> Installation Address: IS OV �,�„ w-1,.c, <br /> City'_���{ Slate:��Zip: ��J 1 <br /> Mailing Address (il diNoront): _ <br /> City: Stale� Zip: <br /> Email 5 w���.3 yr tf�1 �f�of,na.:f_c ow+ Phone• �1z� 25L- l 7 3(. <br /> Total Cost to Install Device(Irom contracfor invoice):$�o ;�1�� <br /> Please vnffy the followlny: <br /> _ - _ . __ J am the owner.otthe property.where.thebackwater_prevention device.wasJnstalled._ _._ __. <br /> [,�I worked with the contraclor to determine the localion for the backwater preventlon device and <br /> understand that the decision regarding Ihe location of the device was mine. <br /> [�My contractor instructed me how ta access, inspect,and maintein the device. <br /> [,�1 undersland that I am responsible for maintaining Ihe backwater prevenlion device and keeping <br /> it in good working order, unless it Is inslalled in Ihe city�ghl•of-way. <br /> [�If I sell my property, I will make potential buyers aware ol the backwater prevention device and <br /> the nced lo inspect and maintain it on e reguler basis. <br /> �am enclasiny all 01 the necessary paperwork(use Ihe yellow Rebate Submitlal Checklisl). <br /> Salect hom tha following: <br /> [� The conlrector idenlified downspouts or alher dralnage Ilines Ihal were connected to my sewer <br /> line(belween my house and th�installed dovice) and removod,or rerouted them. <br /> [�To my knowledge, my property has no downspouls or other dr�inago connected to my sewer lino <br /> (between my house and Ih4 installed device). <br /> ❑ There are downspouls or other drainage lines connected lo my sewer line(belween my house <br /> and the inslalled device). I undersland lhat leaving Ihese conneclions creates a nsk of flooding <br /> e�d I accepl thal risk. ' <br /> I � <br /> Slpnafure�. < <.��Dafe 3' 9— � � <br />