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�� .. — <br /> . ' <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: <br /> InslallaUon Address:_�Q,j �P�01'" _ <br /> c�ry:' �i�Y'���- sc�te: l,//� ziP: 48��1 <br /> Maliing Address(HdilferenQ: <br /> City: State: Zip: <br /> Email: Phone:j,� y0�-�'(/�l <br /> Total Cost to Inslall Device(from eontractor lnvolce): S �?�J -� <br /> Please verHy ths tollowing: <br /> �am the owner of lhe propeRy where the backwater prevention device was fnslailed. <br /> �worked with the contractor to determine the Iocation for Ihe backwater prevenUon device and <br /> understand thal the decision regarding the Iocation ol the devica was mine. <br /> �My contractor Instructed me how to eccess, inspect,and maintaln the device. <br /> �understand thet I am responsible for maintaining the backwater prevention device and keeping <br /> It In good working order,unless it Is Installed in lhe city�ightol-way. <br /> �f I sell my propeAy, I wlll make potentlal buyers eware of the backwater prevention deWce end <br /> the need to inspect and meintaln ii on a regutar basis. <br /> ❑ I am enclosing all of the neeessary papenvork(use the yellow Rebate Submiqal Checklisl). <br /> Select from lhe Iollowing: <br /> �The contractor idenflfied downspouls or other dreinage Ilinos that ruere connected to my sewer <br /> Iine(between my house end the Inslalled devfce)and removed,or rerouted fhem. <br /> �my knowtedge, my property hes no downspouts or other drainage connected to my seNer line <br /> (beNveen my house and the inslalled device). <br /> ❑ There are downspoute or oNer drelnage lines connected fo my sewer line(behveen my house <br /> and lhe Installed device). I undera�-nd that leaving these connections creates e risk of flooding <br /> 1� a and I accept thal risk. <br /> Slgnafure R� � Data /Z - �' ` /! <br />