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Backwater Prevention Device Rebate Pcogram <br /> Rebate Application Form <br /> Property Owner Name: Q�t)ts.�'l_ J ' `Po rens o n <br /> Installation Address: !�/ Cr0 0 �2— <br /> City:�VEI"� State: 0. Zip: 4 u�,01 <br /> Mailing Address(if diflerent): ? <br /> City: Siate: Zip:_ <br /> Email: 1'i71.5@0.l� �O IV ����ri'. � l�'. Phone: (y,tS) �.5� —I fCCI� <br /> Total Cost to Install Device (from contractorinvoice): $ ��S3 � • �C� <br /> Please y the foilowing: <br /> I a the owner of the property where the backwater prevention device was installed. <br /> I worked with the contractor to determine the location for the backwater prevention device and <br /> understand that ihe decision regarding the location of the device was mine. <br /> �NJy contractor instructed me how to access,inspect, and maintain lhe device. <br /> �y�i understand that I am responsible for maintaining the backwater prevention device and keeping <br /> i n good working order, unless it is installed.fn the city right-of-way. <br /> If I sell my property, I will make polential buyers aware of the backwater prevention device and <br /> �need to inspect and maintain it on a regular basis. <br /> I am enclosing all•oF ihe necessary papenvork(use the yellow Rebate Submittal Checklist). <br /> Select from the following: <br /> The contractor identified downspouts or other drainage Ilines that were connected to my sewer <br /> Iine(belween my house and the installed device)and removed, or rerouted ihem. <br /> ❑ To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> ❑ There are downspouts or other drainage lines connected.to my sewer line(beriveen my house <br /> and the instailed device). I understand that leaving these connectio�s creates a risk of flooding <br /> and I accept that risk. <br /> Slgnature �0�� Date /� <br />