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Backwater Prevention Device Rebate Program . <br /> Reb pplication Form <br /> f � � <br /> Property Owner Name: �ES � d n "}a � <br /> Instal�ation Address: 1320 CA fhin �hf CY4ll?', <br /> City: �VQYP� state: IAl/� Zip: �Bwl <br /> Mailing Address (il diNeren!): <br /> City: Slate: Zip: <br /> EmaiL bolv�2vv�c�nU.n�2 @ qvY�C�i� 'Gpm Phone: �}?5 ) 25Z-q K�I <br /> �� <br /> Total Cosl to Instail Device((rom confrac�orinvoice): S 2, �U —' <br /> Please verify the following: <br /> �J I am the o�vner of the property where lhe back�vater prevention device was installed. <br /> � I worked with lhe contractor to determine'the localion for the backwater prevention devir,e and <br /> u�derstand that the decision regarding the location of the device was mine. <br /> �My contractor instructed me how to access, inspect, and maintain the device. <br /> � I understand that I am responsible for maintaining the back�valer prevention device and keeping <br /> it in good working order, unless il is installed in Ihe cily right-o(•way. <br /> �If; sell my property, I will make polential buyers a�vare of the backwater prevention device and <br /> the need lo inspect and maintain it on a regular basis. <br /> ,�j�l am endosing all of the necessary paperwork (use the yellow Rebale Submittai Checklisl). <br /> Select from the fnllowing: <br /> ❑ The conlractor idenlihed downspouts or other drainage Ilines ihat�vere connected to my sewer <br /> line(behvaen my house and the installed device)and removed, or rerouted them. <br /> �To my knowledgc, my property has no downspouts or other drainac�e connecled to my sewer line <br /> (betvieen my house and the installed device). <br /> ❑ There are downspouls or olher drainage lines connected fo my sewer line (between my house <br /> and the inslalled device). I understand that leaving these connections creates a risk of flooding <br /> and 1 accept lhat risk. <br /> , ��� <br /> �.. - <br /> signature Date b-1-15 <br />