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� Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> ---- - - -- <br /> Properly Owner Name: i I I � �� _—_—___ ___ _ <br /> ��cl",J�_ �-— - <br /> Installation Address: ----- <br /> CitY ��v'W'�' ------ Sl�te: ��-2ip:���� I <br /> Mailing Address (il dil/eronf) ______ ____ -- <br /> Cily: Slale: _- Zip' — --_— <br /> i Email: �1�' 1 C�-����G'� . �. T�l�Z�Phone: W��!��`7 <br /> .�_ <br /> ITotel Cosl to Instail Device (Irom contractor invoir.e): $ _____ <br /> Please verify the following: � � � <br /> � I am lhe owner of the property where the backwater prevention Aevice was installed. <br /> ,[� I worked with the coMractor to determine the location for the backwater prevention dewce and <br /> understand lhat Ihe decision regarding the location of the device was mine <br /> �"My conlractor instructed me how tu access, inspect, and mamtain ihe device. <br /> � I undersland thal I am responsible for main!aining the backwaler prevention device and keeping <br /> il in good working order, unless il is installed in�he cily righl-o(-way. <br /> �If I sell my property, I wili make potenlial � yers aware of the backwater prevenlion device and <br /> lhe necd fo inspecl and maintain il on a regular hasis. <br /> ,� I am enclosiny alt of the necessary papenvork (use lhe yellow Rebate Submittal Checkhst) <br /> Select lrom the tollowfng: <br /> � The conir�clor idenlified downspouts or olher drainage Ilines�hal v�ere connected lo tny sewer <br /> hne (between my house and the installed device) and removed, or rerouted ihem. <br /> [� To my knowledge, my property has�o downspouts or other drainage conneded to my sewer line <br /> (between my house a�d Ihe mslalled device). <br /> �� There are duwnspouls oi olher drainage lines conneded to rny sewer line (between my house <br /> and lhe inslalled device) I undersland thal�eaving ihese connecllons creates a risk of flooding <br /> and I acr.ept lhat risk. <br /> I , <br /> _ / '� ��' �� - <br /> Signature % Date � '- <br />