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Backwater Prevention D.evice Rebate Program <br /> Rebate ApplicatiQn Form <br /> PropertyownerName: �e�V C6tV�tn �G�hj.Q,�S <br /> Installation Address� �'I"�I5 �.U�I��1�— <br /> City: FVP�V�'TI State: ��_Zip:^I � vw <br /> A7ailing Address(if diNerenf): <br /> City: State: Zip: <br /> Emaii: C�_ �_l`�����1��� Phone: (`}'2�j�b� - IB�� <br /> Tolal Cosl lo Install Device ((rom confracforinvoice): S Z ''��� •gg <br /> Please verify the following: <br /> �I am the owner of the property v�hcre the back�vater prevention device was installed. <br /> � I worked with the coniractor to determine Ihe location(or the backwater prevention device and <br /> understand that the decision regarding lhe location of the device was mine. <br /> A9y wntraclor instructed me how to access, inspecl, and maintain the device. <br /> I understand ihat I am responsible for maintalning ihe backwater prevention devir.e �nd keeping <br /> it in�ood evorking order, unless il is installed in the city right-o(•way. <br /> � If I sell my property, I�vill make polential buyers aware of the backwater prevention device and <br /> the need lo inspect and maintain it on a regular basis. <br /> � I am enclosinc�all of Ihe necessary papenvnrk (use Ihe yeitov�Rebate Submittal Checklist). <br /> Select from thc (ollo�ving: <br /> ❑ The contractor identilied do�vnspuuls ur oRier drainaye Ilines that�vere connected to my se�ver <br /> line (behveen my house and Ihe mslalled device) and removed, or rerouted them. <br /> � Ta my knowledge, my property has no downspouts or ofher drainage connected to my sewer line <br /> (behvecn my house and Ihe installed device). <br /> ❑ There are downspouts or other draina<�e lines cnnnecled to my sewer line (between my house <br /> and Ihe inslalled device) I under=t�nr1 that ieavinc� these conner.lions creates a risk of tlooding <br /> and I accept lhat risk. <br /> Signafum .u� �l �L J(� Date � -1 I_�_� <br /> t <br />