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;___ ----- --- - -- -- -�-- -- -- --- - --- ---- -- ---- -- <br /> Backwater Prevention Device Rebate Program <br /> . Rebate Application Form <br /> Property Owner Name: L VC( e.� ��/1�fL l I <br /> Inslallation Address:�'���__ <br /> City:���� State: Zip: � O oZ0 � <br /> Mailing Address(if diBer�nt): \����(?,�3�� <br /> City:�,�CntlC� [�� State: �_Zip: ���n� <br /> Email: I�-M��' �YP' ��O�L��� � ��`'�. Phone: (��j S�� `�l� <br /> Total.Cost to Insta!I Device (from contractor invoice): $ <br /> Please verify the tollowing: <br /> �am the owner oi the property where lhe backwater prevenlion device was installed. <br /> � worked wilh lhe conlractor to determine Ihe location tor the backwater prevention 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 lhe device. <br /> I understand that I am responsible for maintaining the backwaler prevenlion device and keeping <br /> il in good working order, unless il is insta�led in ihe cily right-of-way. <br /> �Ii I seli my propetty, i will make potential buyers aware of Ihe backwater prevention device and <br /> the need to inspect and maintain it on a regular basis. <br /> � i am enciosing all of the necessary papenvork(use Ihe yeliow Rebate Submiltal Checklisl). <br /> Select irom the foliowing; <br /> ❑ The contraclor idenlified downspouts or other drainage Ilines lhat were connecled to my sewer <br /> line(behveen my house and the installed device)and removed, or rerouted lhem. <br /> � To my knowledge, my property has no downspouts or olher drainage connecled fo my sewer line <br /> (belween my house and ihe installed device). <br /> �� There are downspouts or olher drainage lines r,�mnected lo my sewer line(between my house <br /> and the installed device). I undersland thal leaving lhese conneclions creates a risk of Ilooding <br /> and I accept that risk. <br /> Signafure � _Date � ��� <br /> � <br />