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� <br />�� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: ��65 E�/� � /'L%lu.m/tii <br />Installation Address: 7 � � <br />I <br />Ciry: � V � r�'CT- State: L�(� Zip: �t �' Z v 1� 1 ��'� <br />Mailing Address (ildiNerenfJ: <br />City: <br />State: <br />i -/ <br />Email: w.� �,�. ' es r k-( ��sa� c��y Phone: (��� 3S�Y -�%�q`f' <br />Total Cost to Install Device (from contracfor invoiceJ: $�c�%� .�� <br />Please verify the following: <br />�am lhe owner of the property where the backwater prevention device �vas installed. <br />� <br />� I worked with the coNraetor to determine lhe localion for lhe backwaler prevention device and <br />understand lhat lhe decision regarding the localion of lhe device was mine. <br />[t�]�My contraclor instructed me how to access, inspect, and maintain the device. <br />�undersland that I am responsible for maintaining Ihe backwaler prevention device and keeping <br />it in good working order, unless it is inslalled in lhe ciry right-of-way. <br />�'If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need lo inspecl and mainlain it on a regular basis. <br />I am enclosing all of Ihe necessary paperwork (use the yellow Rebate Submiltal Checklist). <br />Select from the following: <br />❑ The conlractor idenlified downspouls or other drainago Ilines that were connected to my se�ver <br />line (between my house and lhe installed device) and removed, or rerouted them. <br />❑ To my knowledge, my property has no downspouts or other drainage connecled to my sewer line <br />(�en my house and the installed device). <br />There are downspouls or other drainage lines connecled lo my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of tlooding <br />and I accept that risk. <br />Date .� — Z. � ZD�'.�/ <br />