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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name� �'�''"' �Ir�' <br /> Inslallalion Address: � J ��+ 'Jk�v � <br /> Cily: W�►"��� State: W� _2ip: /yZU � - <br /> Mailing Address(iI dillerent): <br /> Cily: Slale: Zip; __ <br /> Email: _ Phone: ( ) <br /> Total Cost to Install Device (from contracfor invoice): $ <br /> Please verify fhe following: <br /> [� I am lhe owner of the properly where the backwater prevention device was installed. ' <br /> �, I worked willi the contractor to determine the loc�tion tor the backwaler prevention device and <br /> understand lhat Ihe docision regarding the location of tho dovice was mine. . . . . <br /> [� My contractor inslructeA me how to access, inspect, and maintain the device. <br /> � I understand that I am responsibla (or maintaining the backwater prevention device and keeping <br /> il in good working order, unless it is installed in Ihe cily right-of-way. <br /> � If I sell my proporty, I will mak�polential buyers aware o(tho backwater prevanlion devico and <br /> tho need to inspoct and maintain it on a regular basis. <br /> � I am enclosing all of the necess�ry paperwork(use Ihe yelloiv Rebate Submiltal Checklist). <br /> Select from lhe following: <br /> rJ The conlractor identified downspbiils or other dr�inage Ilines Ihal were conneded tn my sewer <br /> Nne (between my house and Ihe installed device)and removed, or rerouted them. <br /> � To rny knowl�dge, my properly has no downspouls or olher drainaye connected to my sewer li,ie <br /> (belween my house and ihe installed dewce). <br /> ❑ There are downspouts or olher drainage lines connected to my sewer line(botween my house <br /> and the installed device). I understand that Ieaviny these connections creales a risk of floodiny <br /> and I accept that risk • <br /> •Signature Date �✓ ��/�/ <br /> � <br />