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Backwate� Preventian Device Rebate Program <br />Rebate Application Form <br />Property Owner Name: <br />Installation Address: <br />City: �9/%,2�� Slate: <br />Mailing Address (i(dilferenlJ: <br />City: <br />Email: <br />State: <br />Total Cost to Install Device (f�orn confrectorinvoice): L+ <br />Please veriFy the following: <br />z�P:�G.��1�3 <br />Phane: (�� <br />� <br />i • <br />I am Ihe ovmer of the property where the backwater prevention device was instailed. <br />f�� worked with the contractor to determine lhe location for lhe backwater pr�vention device and <br />!� understand that lhe decision regarding the location of the device was mine. <br />�My contractor insirocted me how to access, inspecl, and maintain lhe device. <br />(�� understand thal I am responsible for maintaining the backwaler preven�ion device and keeping <br />/ it in good working order, unless it is inslalled in the city righl-of-way. <br />If I sell my property, I will make potential buyers a�vare of the backwater prevention device and <br />lhe need to inspect and maintain il on a regular basis. <br />(��I am enclosing all of Ihe necessary papenvork (use Ihe yeltow Rebaie Submitlal Checklist). <br />Select om the following: <br />he contractor identified downspouts or other drainage Ilines that were connected lo my sewer <br />line (between my house and lhe inslatled device) and removed, nr rerouted ihem. <br />rj To my knowledge, my property has no downspouls or olher drainage connecled to my sewer hne <br />(between my house and the installed device). <br />❑ There are downspouts or olher drainage lines connected lo my sewer line (betveeen my house <br />and lhe installed device). I undersland Ihat Ieaving lhesc connections creales arisk of Ilooding <br />and I accept lhat risk. <br />Signature !� �� � �' Date � �� <br />� <br />