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i Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> Property Owner Name: ��" l�-`(P 'F" � ��--� <br /> Inslal�ation Address:_��Q_V,���_\�� (l�U�—���� —_ <br /> City: �U�`�-� __State:_(�- __Zip�__ ___ <br /> Mailing Address(if di!(erent): _______. <br /> City: Slate: Zip: <br /> Ema�i:�n�e�^� rn -h er � �� Phone:({�33�1 -0� yz--� <br /> v' ( r contractorinvoice : S � <br /> � <br /> Total Cost to Install De ice ( ro n ) � _ <br /> Please verify the following: <br /> I am lhe owner of lhe properly where the bacfnvater prevention device was installed. <br /> ❑ I worked wilh lhe conlraclor to determine the location for lhe backwater prevenlion device and <br /> understand 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 /> ��understand that I am responsible for maintaining Ihe backwaler prevention device and keeping <br /> it in good working order, unless it is installed in the city right-of-way. <br /> If I sell my property, I will make potential buyers aware of ihe backwater prevention device and <br /> the need to inspecl and mainlain il on a regular basis. <br /> I ,�I am enclosing all of lhe necessary papenvork (use the yellow Rebate Submillal Checklist). <br /> Select from the following: <br /> ❑ The conlractor identified downspouls or otner drainage Ilines thal were connected to my sewer <br /> line(between my hause and lhc inslalled devicej and removed, or rcrouled lhem. <br /> ❑ To my knowledgi�. my property has no downspouts or other drai�age connected to;ny sewer line <br /> (belv✓een my hous� and the installed device). . <br /> ❑ There are downspouts or olher drainage lines connecled to my sewer line (behveen my house <br /> and lhe installed device). I undersland thal leaving these connections creales a risk o(flooding <br /> and 1 accept that risk. <br /> Signature � � ��Da�e���✓�(c� ~ <br />