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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: �_�,i <br />Installation Address: <br />Ciry: �v�e��%i- ,'State: �✓,B� Zip. 947A_o/ <br />Mailing Address (if dillerenf): <br />Ciry: <br />State: <br />EmaiC (�n.�� � r c,�g� .�CF" Phone: (!/�' 2!� 44 _� <br />Tolal Cost to Inslall Device (from confractorinvoice): $ 2�1,. .9N <br />Please veNfy ihe following: <br />�'1 am the owner of the propeRy wt;ere the backwater prevention device was instalied. <br />� worked with Me wntractor to determine the location for the backwater prevention device and <br />understand that the declsion regarding the location of the device was mine. <br />�My contractor instructed me how to access, inspect, and maintain the device. <br />�understand that I am responsible for maintaining the backwater prevention device and keeping <br />it in good working order, unless it is installed in the city right-of-way. <br />� I sell my property, I will make potentiai buyers aware of :he backwater prevention device and <br />Ihe need lo inspecf and maintain it on a regular basis. <br />�am enclosing all.ot the necessary papenvork (use the yellow Rebate Submitlal Cliecklisl). <br />Select from the following: <br />�he conhactor identifled downspouls or other drainage Ilines that were connecled to my sewer <br />line (between my house and the instal!=d device) and removed, or rerouted them. <br />[[}�To my knowledge, my property has no downspou[s or olher drainage connected to my sewer line <br />(between my house and Ihe inslailed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (behveen my house <br />and the installed device). I underetand that Ieaving these connections creales a risk of Ooodi�g <br />and ! accept that risk. <br />- .; i �./i.�s� . .� ' � ' <br />