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�Backwater Prevention Device Rebate Program <br />� Rebate Application Form <br />Property Owner Name: .�`��_�]�+I�y <br />Inslallation Address: _ % � � ��—�11`� `-' — <br />City:�%�S_1�—.Slate: W t�\. Zip: ZQl <br />11ailing Address (if dilinrent) <br />Ciry' Sta1e: _ Lp:.___ <br />Email: M�T�10���Z� �-'•�LL � C�1�Phone: (� Zb �� �1_ <br />Tn1al Cost to lnstall Device (from confractorinvoice). S ��31 �Lp__—_ __: __-__ <br />Please ��erify the following: <br />�lj lam the owner o( the prnpeAy where lhe backwator prevention devlte was installed. <br />� I worked wilh the contrar,tm ta delermine Ih? loce6on tor the backwater prevenlion device and <br />understand that Ihe decision rec�arding lhe IocaUon ot tt�e devico was mine. <br />j� My contracror instructed me howdo access, inspect, and'maintain lhe device <br />� hundersland thati am responsible for maintaming the backwater prevention device and keeping <br />d in good workiny order, unless�it is inslalled in the city nghl-ot-way. <br />� If I scll my property, I�vill make potenlial6uyers aware of the beckwater prevention devir,e and <br />Ihe neeA�to mspecl and maintain it on a regular•basis. <br />�j I am enclosng all of Ihe necessary papenvoik (use Ihe yellow Rebate Submittal Checklist�. <br />SMect from-lhe tollowing: <br />❑ The contraclor identified downspuuts or other drainage Ilines that were connected to my sewer <br />linc (betweon my house and the installed device)�and removed, or rernuted them. <br />� To my knowtedge, my property has no downspouls or other dminage connected lo my sewer line <br />(bclweten my house and Uic installed Ar.vica). <br />❑ Thero arn OOwnspout5 or other drainage lines connected to my Sewer linr. (6CC,vccn my hCuse <br />�nd lha inslallud dr.vicr.). i unJeistand lhat leavm9 Ihese comiecliona crcntes a risk of pooding <br />and I accepl lhal nsk. <br />DA�e 3 - zs� 1 � <br />� <br />