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Backwater Prevention Device Rebate P�ogram <br /> Rebate Appiication Form <br /> �— � -- - _ , <br /> i Property Owner Name �C� f�O� I �I�� I <br /> iInstallationAddress _ �.'�Z�j _.rC-T�H2_ ��t�T ___ _ ___ <br /> ' CitY --CS-���� — - - — State WI1 Z�P _ _��2G I _ <br /> Maiiing Address(il diflerent) _. . ._ <br /> iCity'--_ -- — -- - State _ _ lip _,— --------- <br /> ' FinaiC ---- __ Phaie. ( )__ I <br /> Total Cosl to Install Device (Irorn contr�ctor invoice) $_ _ <br /> __------ , <br /> Please verify the following: <br /> � I am ihe owner ol the property where lhe backwaler prevenhon device was installed <br /> � I worked wd'i the contractor to determme the location for the backwater prevenhon dewce and <br /> understand hal lhe decision reyardiny the IocaUon of Ihe device was mine. <br /> �/j My contractor mstructed me how�o access, insped, and maintain the dev�ce <br /> �' I understand that I am responsible for maiMaining Ihe backwaler prevenlion device and keeping <br /> i� In good workmg order, unless it is installed in the cily right-of��vay <br /> � If 1 sell my propeity, I wdl make polential buyers aware of the backwaler prevention devlce and <br /> the need to mspect and mainlain it on a regular b:�sis <br /> � I am enciosing all ol lhe necessary papenvork (use Ihe yellow Rebale Submit�al Checkhstl. <br /> Seiecl lrom the following: <br /> ��-,The coniractor idenldied downspouls or olher drainape Ihnes�hat were conner,ted lo my sewer <br /> Imc(between my housc and the mstalled device)and remaved, or rerouled them <br /> !�I71 Tn my knowledye, my property has no duw�spouts or other Arainage connecled lo my sewer line <br /> �r��(bebvicen my house and the mslalled dewce). <br /> � � There ar�downspou�s or olher drainaye hnes connecled lo my sewer hne(between my huuse <br /> and ihe mslalled device) I undersland that Ieawng Ihese connecUons creates a nsk ol Iloodmy <br /> and I ar.cept thal nsk. <br /> i� <br /> Slgnamre,_��`�`�-z =_= � .. Date I 15I __ <br />