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/� Backwater Prevention Device Rebate Program <br /> � Rebats Application Form <br /> -------_ _— --- ------ <br /> Pro��erty Owner Namc. �Js,y�10"�-,..�_�������1�� <br /> � • � p �' <br /> I Installation Address _?j���,s-��P�4-'�1�_4� --- <br /> I Cily: _� --Statc __\N a�__Zip�Q1�t11 — — <br /> Mailing Address (ilddlerenf) �5 �S �:,�he_�2. <br /> City: ��:� Statc �_ ---Z�P�3A� --- <br /> Email�'�Lt'h?k16P �i0.CS�C�,CQrJICaS�F'hone: (�Z� 3�$—'��� <br /> Total Cosl to Install Device(lrom conUacfor .ivoice) $��3�'�o - I <br /> 1 <br /> Please verify the following: <br /> � I am Ihe owner of the propr.rty where ihe backwaler prevention device was mstalled. <br /> `'� I worked with lhe contractor to determine the location for lhe backwater prevention device and <br /> understand thal the decision regarding the location of the device was mine <br /> �' My contractor instrur,led me how to access, insper.t, and maintam the device <br /> `� I understand that I am responsible for maintaining the backwater preveniion device and keeping <br /> it in good working nrAer, unless d is installed in fhe city nght-of-way <br /> `� If I sell my propeAy. I wi�l make polential buyers aware of�he backwafer prevenlion device and <br /> the need to inspec� and maintain it on a iegular basis <br /> 0.p I am enr,losing all nf the necessary paperv�ork (use the, yellow Rehate Suhmittal Checklist) <br /> t <br /> Sclect from the following: <br /> � ] The contractor iclenti(�d downspouts nr nlher drainage Ilines that were r.onneMed to my sewer <br /> line (behveen my house and Qie installed devir.e)and removed, or rerouted them <br /> �j To my knowledge, my properTy has no downspoitls or olher drainage cunnected to my sewer line <br /> (between my house and the installed device) <br /> � J There aic downspouls or other drama�e lines connecled to my sewer bne (bet�vren m�� house <br /> and the installed device) I undersland that leaving these connechons creales a risk of tloodmg <br /> and I accept that nsk <br /> ,--' � <br /> Signature _ Date_��b`1� _ <br /> � - -- - <br />