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� <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owncr Name: F vn � �-�n 2� w E ��- <br />Installation Address: �lZ � Col b y Av c <br />Ciry: �ve�C t� State• W% Zip: 9�'2 �� 1 <br />Mailing Address (ildiNerenf): <br />c�y: <br />Email: <br />State: <br />Zip:_ <br />Phone:( ) <br />Total Cost to Install Device (Irom contractorinvoice): 5����iZ <br />Please verffy the following: <br />[� am the owner of the property where Ihe backwater prevention device was installed. <br />�worked with the contractor to determine the location for the backwater prevention device and <br />undersland that the decision regarding the location o( the device was mirie. <br />[�My contractor insiructed me how lo access, inspect, and maintain the device. <br />�understand that I am responsible for maintaining the backwaler prevention device and keeping <br />it in good working order, uNess it is installed in Ihe city right-of•way. <br />Q�I( I sell my property, I will make poteniial buyers aware oi the backwaler prcvention device and <br />the need to inspect and mamtain it on a regular basis. <br />[� I am enclosing all o( Ihe necessary paperwork (use Ihe yellow Rebale Submittal Checklisl). <br />Select (rom the tollowing: <br />�he conlractor identi6ed downspouts or olher drainage Ilines that were connecled to my sewer <br />line (belween my house and Ihe installr.d device) end removed, or rerouted them. <br />�To my knowiedge, my property has i�o downspouts or other drainage connected to my sewer line <br />(beRvecn my house and the instalied device). ' <br />❑ There are do�mspouts o� olher drainage lines connecled lo my sewer line (between my housc <br />and the installed device). I understand thal leaving these conneclions creates a risk of Oooding <br />and I accept that risk. <br />r <br />Signatu Date �-17-/S <br />