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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Properly Owner Name: <br />Installation Address: <br />City. Ej----State:_�fiffifOCIn*ip: g9W1 <br />Mailing Address (it different): _�v swT ff it <br />City: State: Zip: <br />Email: �P'h/one: ( ) <br />Total Cost to Install Device (from contractor invoice): $ gygq—. <br />Please verify the following: <br />M<am the owner of the property where the backwater prevention device was installed. <br />[;�Ii'worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />®-ly contractor instructed me how to access, Inspect, and maintain the device. <br />(understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />EU�Irl sell my property, I will make potential buyers aware of the backwater prevention device and <br />�,,� <br />the need to inspect and maintain it on a regular basis. <br />Owl am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). <br />Select from the following: <br />The contractor identified downspouts or other drainage (lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />M40�`rmy knowledge, my properly has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />r �( <br />Signature � Date l.�I .� <br />