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Backwater Prevention Device Rebate Program ' <br /> Rebate Application Form <br /> Property Owner Name: J �L►�n�S-1�.�2L t'_1C�Lz1 I' <br /> Installalion Address _��__�� 1��� <br /> City: ��� Stale: IA ) Y1 Zi;�:� sc�(�� <br /> t <br /> Mailing Address (il dillemnQ: <br /> City: _ Stale' Zip: <br /> Email: Phone: (�,��' —r� � I <br /> Total Cost to Install Device (from contractor invoice): 5_���� D g —� <br /> Please verify the following: <br /> �J I am the ovdner of lhe properiy where lhe backwater prevenlion device was installed. <br /> � I �vorked with the contractor to determine the location for�he backwater prevent.nn devic� and <br /> undersfand Ihal the dc�ision regarding the localion o(the device was mine. <br /> � Niy contrector inslrucled me how to access, inspect, and mainlain lhe device. <br /> �J 1 understand that I am responsible fnr mainlaining ihe backwaler prevention device and keep�ng <br /> il in good�vorking order, unless it is installed in Ihe cay right-of-way. <br /> �j If I sell my properly, I will make polential buyers aware of the backwa:er prevention device and <br /> fhe need to inspecl and maintain i� on a reguiar basis. <br /> � I am enclosing all'of the necessary papenvork (use the yellow Rebale Submitlal Checklist). <br /> Selccl from the following: � <br /> �'( The contractor identified downspouls or other drainage Ilines that were connected to my sewer <br /> line (belween my house and Uic installed device)und removc�t,ur rerouled lhem. I <br /> [� io my knrnvledge, my property has no downspouls or olher drainagc eonnected lo my sewer hnc <br /> (between my house and the inslalled device). <br /> (—J There are downspouls or olher drama�e lines connecled to my sewer line (behveen my house <br /> and Ihe installed device) I undersland that leaving lhese conneclions creates a risk of flooding <br /> and I accep�thal risk. <br /> l/:/ <br /> � <br /> � / � 7,R�IG <br /> SignatureJ / i.o.S �'��s Da[e .Z— '� ' ��L_ <br /> �� i <br /> I <br /> I <br />