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Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Prope�tyOvmerName: �u�[e`� /v�5S1'I iN/�.y� <br /> Installalion Address: /y32 Ce�b n 1��'� <br /> Cily:_ �✓Pnr%/ State: �✓A Zip: �� � <br /> Ivlailing Address(i(differen!):_ <br /> City: _ Stete: Zip: <br /> Email: c��C�d���7 ��a.�.�,, ,c�r,,,, Phone: (�1��5'���{�'] <br /> Total Cost to Install Device(lrom conlraclorinvoice): S .2 y��• 30 <br /> Please verify the following: <br /> � I am the owner of the property�vhere the backwater prevention device was installed. <br /> (� I v�orked with lhe contractor to determine Ihe location for the backwaler prevention device and <br /> understand thal lhe decision regarding the localion of.the device v�as mine. <br /> � My contractor instructed me how lo access, inspecl, and mainlain Ihe device. <br /> [� I understand thal I am responsibte for mainlaining lhe back�vater prevenlion device and keeping <br /> il in good working order, unless it is installed in the city righl-of-way. <br /> �' if I sell my property, I will make potential buyers aware of the backwaler prevention device and <br /> lhe need lo inspect and maintain il on a re�ular basis. <br /> (� I am enclosin� all of�hc necessary paperwork (use U�e yellow Rebate Suhmiltal Checkli.t). <br /> Select irom the following: <br /> ❑ The contraclor iden�l(ed dotivnspouls or other drainage Ilines thal�vere con�ected to my sewer <br /> line(between my house and ihe installed device)and remnved, or rerouted them. <br /> �7' Tn my kno�vledge, my property has no downspouls or other drain2ge connected lo my sewer line <br /> (belween my ho�ise and lhe installed devicc). <br /> ❑ There are do��mspouls or other drainac�e lines connecled lo my se�ver line(between my house <br /> and Ihe insla'Ied device) I underslnnd that le�ving lhese connr.chons creales a risk oi flooding <br /> and I accept that nsk <br /> Sfgnafure � � Date � %-� Sy <br />