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Backwater Prevention Device Rebate Program <br /> E„ Rebate Application Form <br /> -- — - - ___. __--- <br /> Property Owner Name: . !J _��j_�JL ,��Qi_ <br /> Installalion Address �31� _�^ ,,��y' '� / <br /> City �]f�Q-Y�--— — -State _ULY 1 Z�P-�v�� � — ----- — <br /> Mailing Address(il diHerent): _ � <br /> City' State: Zip: <br /> Email: �1/1,_J_ �(,������Y.�-�-_�__C_bl�Phone. �_�j�_�S._ <br /> Total Cost to Ins1aU Device (Irom confracfor invoice): $_�3�•�_ li <br /> i <br /> Please verify the fotlowing: <br /> [�I am the owner of lhe property where the backwater prevention device was installed. <br /> (�I worked with the conlractor lo determine the location for ihe backwater prevention device and <br /> undersland thal the decision ieyarding Ihe localion of Ihe device was mine. <br /> [�My contractor instructed me how lo access, inspect, and maintain the device. <br /> �nderstand thal I am responsibte for maintaining lhe backwater prevenhon device and keeping <br /> i� in good working order, unless il is inslalled in the city right-of-way <br /> If I sell my property. I wlll make potential buyers aware of the backwaler preventinn device and <br /> e need lo insper,l and maintain it an a re.gular hasis <br /> �_ I am enclosing ail o(ihe necessary paperwork (use the yellow Rebate Submittal Checklist). <br /> Select trom the following: <br /> � J The conlracfor idenlified downspnuts or olher drainage Ilines Ihat were connected to my sewer <br /> (�li e(hel�veen my house and Ihe inslalled devicr.) ,�nd removed, or rcrouted ihem. <br /> o my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (behveen my house and lhe installeA device). <br /> � Thcre are downspouts or olher drainage lines connected to my sewer linc (bclwcen my housc <br /> and the installr.d devicr.) I understand lhat Ieaving these connections creates a risk of tlooding <br /> and I accept ihat risk. <br /> � <br /> Signature Dafe a � �5 <br />