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- --- �----r----- - -- —— -- –--- --- - <br /> Backwater Prevention Device Rebate Program <br /> t„ Rebate Application Form <br /> ;7 � <br /> Property Owner Name: �7� / � <br /> Installation Address: ��� .B ��_ <br /> City: �-✓-e hG V 1 _Stale: VI� Zip: q_��oZD� <br /> Mailing Address(iI dilferent): <br /> City: State: Zip; <br /> r ` 3a- a6 <br /> Email:IC��I'e�i, �b,oc�dl{� . .<J� Phone: (�_�fj___� <br /> Total Cosl to Install De�(rom contractorinvoice): $ oZ� . � <br /> Please verify the following: <br /> i I am the owner of Ihe property where the backwater prevention device was installed. <br /> �I worked wilh the conlractor to determine the localion tor the backwafer prevention device and <br /> understand Ihat the decision regarding the location of the device was mine. <br /> �(v1y contractor instructed me how to access, inspect, and maintain Ihe device. <br /> �I understand that I am responsible tor maintaining the backwater prevention device and keeping <br /> it in good working order, unless it is installed in the city righl-of-way. <br /> �If I sell my property, I will make potential huyers aware of the backwater prevention device and <br /> lhe need to inspect and maintain il on a regular basis. <br /> � I am enclosin5 all of Ihe necessary papenvork(use lhe yellow Rebale Submiltal Checklist). <br /> Select irom the following: <br /> ❑ The contractor identified downspouts or olher drainage Ilines that were connected to my sewer , <br /> line (between my house and ihe installod devica)and rernoved, or rerouled them. _ <br /> �]�To my knowledge, my property has no'downspouls or other drainage connected to my sewer line <br /> (between my house and lhe inslalled device). <br /> ❑ There are downspouls or other drainage lines connecled lo my sewer line (belween my house <br /> and lho inslalled device). I undersland tha�leaving these connections creates a risk oi flooding <br /> and I a�:cept that risk. <br /> Signature � Date '�` �� '�S <br />